2017 VBS Student Application
June 5 - 8, 2017 (Mon - Thurs)
10 AM - 2 PM

Fee: $20 (T-shirts & Lunch included) Check or Cash only. Please pay at the front desk on day 1.

Korean Baptist Church of Austin

Address: 3110 Parker Ln, Austin, TX 78741
Phone: 512-443-2448
Website: http://www.kbca.info

Email address
Registration Form
Name (Last , First Middle)
Your answer
Date of Birth
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Gender
Youth T-Shirt Size
Grade
Your answer
Parent/Guardian Name
Your answer
Phone
Your answer
Address (Street / City / State / Zip)
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Are you KBCA Member?
If not KBCA, what church?
Your answer
Guest of ?
Your answer
Any Allergies? Please describe:
Your answer
Permission to Provide Medical Attention
Please read the information below, complete, and sign your name confirming your approval of the below:

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest care facility and/or to the emergency transport location entered below.

I also hereby authorize the performance of medical, minor surgical or diagnostic procedures, including the administration of local anesthesia that may be deemed necessary or advisable by the attending physician or surgeon in the diagnosis and emergency treatment of my son or daughter in the event that I cannot be reached for direct authorization.

Emergency Transport Location
Your answer
Release Form
I agree to release the Korean Baptist Church of Austin, its successors and assigns from all claims of loss, damage, or injury sustained by the participation in KBCA’s Vacation Bible School, whether caused by the negligence of the church, its agents, employees, or otherwise.

I further agree to indemnify said church, its successors and assigns against any and all claims for such loss, damage, or injury sustained by the participant, whether caused by the negligence of the church or its officers, agents, employees and otherwise.

Parent/Guardian’s Signature:
Your answer
Submit Date
MM
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YYYY
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