Galactic Starveyors VBS
July 17-21
9AM-Noon
Avondale Bible Church//17010 Avondale Road NE// Woodinville, WA 98072
Contact us at 425.788.1311//josh@avondalebiblechurch.org
Child's Name
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Your Address
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Your Phone Number
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Your Email
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Your Current Place Of Worship
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Grade Child Is Entering In The Fall
Child's Dietary Restrictions/Allergies
Emergency Contact Name
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Emergency Contact Number
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Physician Name and Phone Number
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Medical Insurance Carrier & Policy Number
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Is there any medical/allergy information we should be aware of?
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Consent Form
I understand that in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I do hereby authorize Avondale Bible Church as an agent for my child to consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the PHYSICIANS AND SURGEONS ACT and on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It’s understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority & power on the part of our aforesaid agent, to give specific consent to any and all such diagnosis, treatment or hospital care which aforesaid physician in the exercise of his best judgment may deem advisable. I further agree to indemnify and hold harmless Avondale Bible Church, their leaders, agents, sponsors, and any members from any liability or personal injury, loss, or damage that may be sought by any party for any reason whatsoever as a result of said minor(s) participation in the above named event.
I consent to my child participating in the event listed above. I also understand that my child is under the authority of the church leadership and that failure to comply with leadership could result in dismissing my child from this event and my being called to pick him/her up.

I also hereby grant permission to Avondale Bible Church to use photographic images containing photograph/likeness of said minor for various purposes such as printed material, publications, displays, video productions, PowerPoint presentations, etc., as well as for the Avondale Bible Church website on the World Wide Web (WWW). I also acknowledge Avondale Bible Church's right to crop or treat the photographic image at its discretion.

Do you agree with the terms in the medical/photo release as stated above?
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