VBS Weekend 2018 - Polar Blast
First United Methodist Church of Riverside
Vacation Bible School
August 3-5, 2018
Friday & Saturday 9:00 a.m. to 12:00 p.m.
Sunday 10:00 a.m. to 12:00 p.m.
4845 Brockton Avenue
Riverside, CA 92506

**Please complete this form for EACH child attending VBS**
**Children must be age 4 by July 1, 2018**

Cost:
$15 for one child
$20 for two children
$30 for three or more children

Email address *
Participant First Name *
Your answer
Participant Last Name *
Your answer
Grade Entering Fall 2018 *
Address *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Allergies *
Your answer
Medical Insurance Carrier *
Your answer
Medical Policy Number *
Your answer
Hospital Preferred *
Your answer
Doctor's Name *
Your answer
Doctor's Phone Number *
Your answer
Medical Concerns
Your answer
Do you have a friend you would like to be placed with? (We cannot guarantee children will be grouped together, but we'll do our best!)
Your answer
Parent First Name *
Your answer
Parent Last Name *
Your answer
Parent Phone Number *
Your answer
Liability Release: I/ We, do hereby state that I/We are the parent(s) or legal guardian(s) of the above named minor. Should an emergency arise while my child is under the supervision of the staff at First United Methodist Church of Riverside (FUMCOR) Vacation Bible School, I/We do hereby authorize the staff to obtain medical attention for my child. I/We do hereby give consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine during the program period. I/We do hereby release and forever discharge FUMCOR and its employees, agents, officers, trustees, affiliates and representatives from any and all liability of any kind for any claim, demand, action, cause of action, expense, judgment or cost, including without limitation attorneys fees, which arise out of or relate in any manner to the exercise of authority or judgment pursuant hereto, or to the securing, oversight, administration or supervision of medical or other care or treatment on behalf of my child at any time or any travel incident thereto. *
I give permission to take pictures of my child and the pictures can be used for publicity, placed on Facebook and the church’s website. *
A copy of your responses will be emailed to the address you provided.
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