SMBC Vacation Bible School 2019
VBS Registration Form must be completed by a Parent/Guardian for each child attending.
Child's Name *
Your answer
Birth Date (Must be 4 years old by 1/1/19) *
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Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent's Cell Phone *
Your answer
Can this cell phone receive texts? *
Email Address *
Your answer
Parent/Guardian Name (that is completing this form) *
Your answer
Emergency Contact (Name and Phone Number) *
Your answer
Allergies, medical concerns, medications and/or special needs:
Your answer
School Grade (Completed in 18-19 School Year) *
Name of church you attend, if any: *
Your answer
I hereby grant Smith Memorial Baptist Church permission to photograph my child for use on crafts, their website, and/or informational/ promotional purposes (no names or personal information will ever be used). *
Do you agree to the following statement: I , the parent(s) or guardian(s) of the child registered for SMBC Vacation Bible School June 24-28, 2019, do hereby authorize adult volunteers of Smith Memorial Baptist Church as agent(s) for the parent/guardian, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital.I further release from any liability Smith Memorial Baptist Church, and any of its ministries or leaders in the event of an accident en route, during and returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence. *
Insurance Information
Health Insurance Company Name: *
Your answer
Insurance Policy Number *
Your answer
Doctor's Name and Phone Number *
Your answer
Dentist's Name and Phone Number *
Your answer
Date of last tetanus shot (if known)
Your answer
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This form was created inside of Smith Memorial Baptist Church.