VBS 2017 ~ MAKER FUN FACTORY ~ YOUTH VOLUNTEER APPLICATION FORM
2017 Vacation Bible SchoolChinese Gospel Church (CGCM)
60 Turnpike RoadSouthborough, MA 01772
www.cgcm.org/ministries/children
****** JULY 10 - 14, 2017 | 8:00 AM - 4:00 PM ****** ACCEPTING YOUTH ENTERING GRADE 7TH THRU 12TH IN SEPTEMBER 2018 - REGISTRATION ENDS 4/28/2017
*** IMPORTANT ***

TO BE CONSIDERED AS A CGCM VBS 2017 YOUTH VOLUNTEER, YOU MUST BE A MEMBER OF A CHURCH YOUTH GROUP. ALL NON-CGCM YOUTH APPLICANTS MUST SUBMIT A LETTER OF REFERENCE FROM YOUR HOME CHURCH YOUTH PASTOR. PRIORITY WILL BE GIVEN TO CGCM YOUTHS.

YOUTH INFORMATION
LAST NAME
Your answer
FIRST NAME
Your answer
CURRENT GRADE OF SCHOOL
GENDER
DATE OF BIRTH
MM
/
DD
/
YYYY
PHONE
(000-000-0000)
Your answer
E-MAIL
Please enter a valid email address. We will use it to contact you if needed.
Your answer
STREET
Your answer
CITY
Your answer
ZIP
Your answer
ALLERGIES
Food Allergies / Medical / Health Condition If Any
Your answer
CHURCH YOU ATTEND
ALL non-CGCM youth applicants must submit a letter of reference from your home church youth pastor. Priority will be given to CGCM youths.
YEAR OF BAPTISM
Your answer
PARENT'S NAME
(First name Last name)
Your answer
PARENT'S E-MAIL
Please enter a valid email address. We will use it to contact you if needed.
Your answer
DAYS YOU CAN HELP
YOUTH VOLUNTEER T-SHIRT
CHECK SERVICES THAT INTEREST YOU
1) AM BIBLE CAMP - PRESCHOOL
2) AM BIBLE CAMP - ELEMENTARY
3) PM CULTURE CAMP
(CLASS HELPER MAY CHOOSE 4 CLASSES YOU LIKE MOST FROM THE LIST)
*** The list is for Elementary Helper only. It does not apply to Preschool Helper. ***
PARENTAL PERMISSION AND MEDICAL RELEASE FORM
I here give permission to MY SON/DAUGHTER (YOUTH NAME)
Your answer
to take part in the Chinese Gospel church of Massachusetts (“CGCM”) (PROGRAM:) VBS on (DATE:) JULY 10-14, 2017, at 60 Turnpike Road, Southborough, MA 01772. In case my son/daughter has an illness or accident while attending (PROGRAM:) VBS, CGCM and its representatives, agents, volunteers, employees and other special guests (collectively “Agents”) have my permission to make suitable arrangements for medical care and to act for me in any emergency requiring medical attention and that all such medical expenses will be paid by me or the medical insurance plan of my son/daughter. I agree to release CGCM and all its Agents from liability for actions taken and decisions made in the process of providing first aid and obtaining medical care for my son/daughter. It is understood that, if time and circumstances permitted, effort shall be made to contact me, the undersigned, prior to rendering treatment to my son/daughter, but that any of the above treatment will not be withheld if I cannot be reached. I agree to hold harmless and release CGCM and all its Agents from any and all liability that may accrue from personal injuries to my son/daughter. I further understand and agree that I will be responsible for any personal or property damage incurred by my son/daughter while at the premises or grounds of of CGCM and that CGCM and its Agents are not responsible for personal belongings, lost damaged, or stolen.
YOUTH'S DATE OF BIRTH
MM
/
DD
/
YYYY
PEDIATRICIAN'S NAME
(First name Last name)
Your answer
PEDIATRICIAN'S PHONE NUMBER
000-000-0000
Your answer
HEALTH INSURANCE COMPANY
Your answer
INSURANCE ID NUMBER
Your answer
INSURANCE POLICY NUMBER
Your answer
PARENT/GUARDIAN'S NAME
(First name Last name)
Your answer
PARENT/GUARDIAN'S E-MAIL
Please enter a valid email address. We will use it to contact you if needed.
Your answer
PARENT/GUARDIAN'S PHONE NUMBER
(000-000-0000)
Your answer
By electronically signing this, you acknowledge that your on-line consent to the Medical Consent and Release Form is equivalent to a binding legal signature. Please enter your full name again.
(Parent's Signature)
Your answer
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