Children's Ministry Waiver
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Childs Name *
Date of Birth (Child) *
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Grade Level *
Street Address (Child) *
City (Child) *
State *
Zip Code (Child) *
Parent / Guardian #1 Name *
Parent/Guardian #1 Address (if different from child)
Parent/Guardian #1 Phone Number *
Parent/Guardian #1 Email *
Parent/Guardian #2 Name
Parent/Guardian #2 Relationship to Child
Parent/Guardian #2 Address (if different from child)
Parent/Guardian #2 Phone Number
Emergency Contact (person to contact if parent/guardian cannot be reached) *
Emergency Contact Relationship to Child *
Emergency Contact Phone Number *
Please mark as appropriate. Is your child allergic to: *
Required
Are any of the above allergies potentially serious or life-threatening? *
Is your child bringing any medication with him/her? (This is only allowed in extreme cases e.g. allergies, asthma.) *
If yes to above, please list and state dosage. *Please note: Medication should be in its original prescription bottle/package, which should have instructions and the child's name clearly indicated.
Does your child have any physical, emotional, mental, or behavioral concerns or limitations that our staff should be aware of? *
If yes to above, please explain.
Has your child ever had:
Has your child received all required immunizations? *
If my child has a temperature greater than 100.0 F, he/she will be unable to check into children's ministry service until 24 hours fever free. *
In case of medical emergency, I understand the hospital policy requires parental or guardian permission before treatment. I hereby give my permission to a representative of VBC Houston to administer medication as identified above, and to secure proper medical treatment. Parents or guardians will be notified immediately of any medical emergency. *
Digital Signature *
Date *
MM
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YYYY
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