莱城华人基督教会儿童暑期圣经班报名表
Lexington Chinese Christian Church 2019 VBS Application form 7/22 - 7/26 6:30pm - 8:45pm 3-10 yrs old free admission
Name *
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Birthday *
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Age *
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Gender *
Last School Grade Completed
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Address: street *
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City
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State *
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Zip *
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Father's name
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Mother's name
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Parent email address *
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Phone number *
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* If you need a ride, please check this box:
In an emergency when parent/guardian cannot be reached, please contact the following:
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Emergency contact name 紧急联络人姓名: *
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Relationship to child 与儿童关系 *
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Home Phone紧急联络人家庭电话 *
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Cell/Alternate Phone 手提电话 *
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Family Physician/Pediatrician家庭/儿科医生
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Phone #电话
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Medical/Hospital Insurance Company医疗保险公司
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Policy Holder’s Name 保险人
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Does your child have any physical, emotional, mental, or behavioural concerns or limitations that church should be aware of? If yes, please explain. 參加者是否有任何身體、情緒、精神及行為上的顧慮需要教会注意? 若答案「是」, 請列明
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Allergies 任何过敏
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Is your child bringing any medication with him/her? If yes, please list 參加者是否自备药物?若答案(是), 請詳細列出
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Additional Information that May Be Helpful 若有其它有用信息,请说明
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The safety of your child is our primary concern. All precautions will be taken for their well-being and protection.您的孩子的安全是我們的首要关注。我们会采取适当的措施来確保他们的健康及安全。**************************************************I, the parent or guardian, named above, authorize representatives of Lexington Chinese Christian Church (LCCC) to sign a consent for emergency medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the child named above, as deemed necessary. I, named above, acknowledge that I am aware of the possible risks, dangers and hazards associated with participation in the activities including the possible risk of injury to my child, or myself. I, named above, undertake and agree to fully release, acquit and forever discharge LCCC, its pastors, elders, board members, employees, and volunteers from and against any and all claims and demands which we now have, or at any time hereafter may have, because of any and all known and unknown loss, damage, or injuries of any kind whatsoever (including injury, loss or damage due to negligence on the part of LCCC) sustained by the participant as a result of being part of the LCCC Children’s and Youth Ministry activities, as well as of any medical treatment authorized by the supervising individuals representing the church. In case of an accident, although LCCC bears no legal liability, LCCC would try to coordinate the care of the affected parties as a witness of Jesus’ love. 本人為以上參加者的父母或監護人, 授權予莱城华人基督教会負責人, 並代表本人在任何突發意外上簽署同意書, 允許有關的醫生或醫院為上述參加者提供醫療評估或必須的治療。本人清楚參加者在貴教會參加兒童與青少年活動中有潜在风险或可能的意外。本人清楚明白並同意, 參加者在貴教會參加任何教會活动中, 如在任何意外上導致的損失或損傷, 均與莱城華人基督教会及其附属机构(包括牧師、長老、執事与同工)无关,本人都完全免除莱城華人基督教会的所有责任。万一有意外发生,莱城华人基督教会虽然没有法律责任,教会仍将协调关心有关人员,分享耶稣的爱。
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