OURKIDS VBS Registration
OURKIDS VBS is a highly active program that requires the cooperation of all involved. For your enjoyment, please report to VBS physically and mentally prepared for the activities involved. The VBS Director reserves the right to encourage children to be involved only in those activities for which they are prepared.
Email address *
Child's Full Name *
Your answer
Address *
Your answer
City, State, Zip Code *
Your answer
Home Phone
Your answer
Cell Phone *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Age as of August 19, 2019 *
Your answer
Gender *
Parent/Guardian's Full Name *
Your answer
Relationship to Child *
Your answer
Emergency Contact Information
In case of EMERGENCY the following person(s) could be notified:
Emergency Contact #1 Full Name *
Your answer
Emergency Contact #1 Phone Number *
Your answer
Emergency Contact #1 Relationship to Child *
Your answer
Emergency Contact #2 Full Name *
Your answer
Emergency Contact #2 Phone Number *
Your answer
Emergency Contact #2 Relationship to Child *
Your answer
Medical Information
Please visit with VBS Director (Tait Stocking) prior to your child arriving to VBS if there are specific food allergies; lactose intolerance, gluten-free. This will allow us the opportunity to prepare snack accordingly. Please list all allergies including insect stings, hay fever, asthma, etc. in the space provided below.
Child's Doctor *
Your answer
Doctor's Phone Number *
Your answer
Last Tetanus Immunization *
MM
/
DD
/
YYYY
Food/Other Allergies *
Your answer
Please List Any Past Medical Treatments
Your answer
Permission to Administer Medication
Medication
Your answer
Dose
Your answer
Time to be Given
Time
:
Insurance Information
Is the Child Covered by Family Medical/Hospital Insurance? *
Medical Insurance Carrier or Plan Name
Your answer
Name of Insured
Your answer
Relationship to Child
Your answer
Policy ID Number
Your answer
Medical Emergency Disclaimer *
Required
Photography During Event
Photography Consent
Child Pick Up Authorization
ONLY those listed below will be allowed to sign out a child. If for some reason someone other than those listed need to pick your child up at VBS we will need either written permission from the custodial parent/guardian or you may contact Tait Stocking 253-432-9697 to make those arrangements.
Authorized Pick Up Person #1 Full Name *
Your answer
Authorized Pick Up Person #1 Phone Number *
Your answer
Authorized Pick Up Person #1 Relationship to Child *
Your answer
Authorized Pick Up Person #2 Full Name
Your answer
Authorized Pick Up Person #2 Phone Number
Your answer
Authorized Pick Up Person #2 Relationship to Child
Your answer
Is there anyone NOT allowed to pick child up?
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Our Church 253. Report Abuse - Terms of Service