VBS Sign Up
JULY 15th - JULYy 19th
Child's Name ( first last) *
Your answer
Child's Age *
Child's Birthday *
Your answer
Child's Grade Level in School for past school year *
Gender *
Email Address *
Your answer
Address, City, State, Zip Code *
Your answer
Phone Number *
Your answer
Mother's Name and Phone Number *
Your answer
Father's Name and Phone Number *
Your answer
Emergency Contact - Name and Phone Number *
Your answer
Physician - Name and Phone Number *
Your answer
Dentist - Name and Phone Number *
Your answer
Medical History - If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken. *Type N/A if this does not apply to your child. *
Your answer
Does your child have allergies to *
yes
no
pollens
medications
food
insect bites
Does your child suffer from, or has ever experienced, or is being treated currently for any of the following: *
yes
no
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap
Does your child wear: *
yes
no
glasses
contact lenses
Please list and explain any major illnesses the child experienced during the last year: (*Type N/A if this does not apply to your child.) *
Your answer
Should this child’s activities be restricted for any reason? Please explain: (*Type N/A if this does not apply to your child.) *
Your answer
For your information, we expect each student to conform to these rules of conduct: 1. No possession or use of alcohol, drugs, or tobacco. 2. No students can drive. 3. No fighting, weapons, fireworks, lighters, or explosives 4. Participation with the group is expected. 5. Respect property. 6. Respect one another, staff, and adult leaders. 7. Respect and comply with event schedules. *Students who fail to comply with these expectations may be sent home at their parents’ expense. *
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. *
Parent Signature (type name) and date *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms