VBS 2019 Registration
Child's Name *
Your answer
Grade entering in the fall *
Additional child attending
Your answer
Grade entering in the fall
Additional child attending
Your answer
Grade entering next fall
Street Address *
Your answer
City and zip *
Your answer
Parent's name *
Your answer
Cell phone *
Your answer
Email *
Your answer
Emergency contact (name and phone number) *
Your answer
Allergies or medical concerns
Your answer
Physicians name and phone number *
Your answer
Primary Insurance Company
Your answer
Policy holder *
Your answer
ID *
Your answer
Group number
Your answer
Statement of Consent: In the event of an emergency requiring medical treatment, I grant permission for any and all medical attention to be administered to my child/children, in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. Electronic signature required. *
Your answer
Permission to use photograph: I grant to Golden Valley Lutheran Church, the right to take photographs of my child/children in connection with Vacation Bible School. I authorize Golden Valley Lutheran Church, to copyright, use and publish the same in print and/or electronically. I agree that Golden Valley Lutheran may use such photographs without my child's name for any lawful purpose, including publicity, illustration, and web content. *
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