VBS 2019 Registration
Registration for Nova Community Church's Vacation Bible School
July 22-26, 2019
Email address *
You must complete a separate registration form for EACH child attending VBS.
CHILD'S INFORMATION
Child's Last Name *
Child's First Name *
Child's Grade in Fall *
Child's Age *
Child's Birthday (MM/DD/YYYY) *
Child's T-Shirt Size *
PARENT'S INFORMATION
Parent's Name *
Street Address *
City *
State *
Zip Code *
Home Phone Number (XXX) XXX-XXXX *
Cell Phone Number (XXX) XXX-XXXX: *
Email Address *
How did you hear about our VBS program? (check all that apply) *
Required
Home Church (if applicable)
MEDICAL INFORMATION
Mother's Name (First and Last) *
Father's Name (First and Last) *
Family or Child's Physician *
Physician's Phone Number (XXX) XXX-XXXX *
Health Insurance Provider *
Policy or Group Number *
Medical Allergies or Concerns (If there are no concerns, please type "none" in the box) *
Food Allergies (If there are no concerns, please type "none" in the box) *
Emergency Contact Name (First and Last) *
Emergency Contact Number (XXX) XXX-XXXX *
Emergency Contact Relationship to Child *
TYPING YOUR NAME IN THIS FIELD WILL REPRESENT YOUR SIGNATURE. I, the undersigned parent or legal guardian do hereby authorize and consent to any x-ray examination, medical or surgical diagnosis rendered under the supervision of the medical staff listed under the provisions of the Medical Practice Act and on staff of any acute general hospital currently licensed by the State of California Department of Health. It is understood that this authority is given in advance to any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to the physician in the exercise of his best judgment. It is understood that reasonable effort will be made to contact the undersigned prior to rendering treatment, but that treatment will not be withheld if the undersigned cannot be reached. Medical expenses will be borne by the child's family and/or health insurance. *
Please type your full name below.
A copy of your responses will be emailed to the address you provided.
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