2017 TSBC VBS Registration
Vacation Bible School at Trussville Southside Baptist Church will be Monday June 19th through Friday June 23rd from 6:00 PM to 8:00 PM. Registration is open to all children from K3 through 6th grade.
Child 1 Name *
Your answer
Child 1 Age *
Child's Name 2
Your answer
Child 2 Age
Child's Name 3
Your answer
Child 3 Age
Child's Name 4
Your answer
Child 4 Age
Parental Consent and Medical Release
I/We, the undersigned parent(s) / guardian(s) hereby consent for my/our child/children to participate in all Vacation Bible School (hereafter known as VBS) activities at Trussville Southside Baptist Church (hereafter known as TSBC). I/We do hereby release and agree to hold harmless TSBC and their staff, volunteers, and representatives, corporately or individually, from any and all liabilities or claims for personal injury, illness, or death as well as property damage and expenses of any nature whatsoever which may be incurred by my (our) child/children while said child is participating in VBS at TSBC. I/We authorize an adult in whose care the minor has been entrusted to consent to medical or dental diagnosis and/or treatment and hospital care to be rendered to my (our) minor child/children on the advice of any physician or dentist or the medical staff of a licensed hospital and/or emergency care facility. I/We do herewith authorize the treatment by this authority and it is granted only after a reasonable effort has been made to reach me/us, the parent(s) and/or guardian(s). I/We, the undersigned, shall assume all financial liabilty and agree to pay all costs and expenses incurred in connection with ambulance transfer, emergency room visit, and all medical and dental services rendered to my/our child/children pursuant to this authorization.

This consent and release shall be in effect from June 19, 2017 through June 23, 2017.

By completing this form, I also indicate my willingness for my health insurance company to be billed for any and all medical fees and services should that be needed.

Health Insurance Provider
Your answer
Policy Number
Your answer
Release and Signature
This consent and release is completed and signed for the purposes of authorizing participation in VBS at TSBC and for any emergency medical treatment in my (our) absence. By entering your name below, you are effectively providing you signature and agreeing to the parental consent and medical release for any children listed on this form.
Parent or Guardian Name *
Your answer
Relationship *
Home Phone *
Your answer
Cell Phone
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms