VBS 2018 Registration
Registration for Nova Community Church's Vacation Bible School
July 23 - 27, 2018
Email address *
You must complete a separate registration form for EACH child attending VBS.
CHILD'S INFORMATION
Child's Last Name *
Your answer
Child's First Name *
Your answer
Child's Grade in Fall *
Child's Age *
Child's Birthday (MM/DD/YYYY) *
Your answer
Child's T-Shirt Size *
PARENT'S INFORMATION
Parent's Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone Number (XXX) XXX-XXXX *
Your answer
Cell Phone Number (XXX) XXX-XXXX: *
Your answer
Email Address *
Your answer
How did you hear about our VBS program? (check all that apply) *
Required
Home Church (if applicable)
Your answer
MEDICAL INFORMATION
Mother's Name (First and Last) *
Your answer
Father's Name (First and Last) *
Your answer
Family or Child's Physician *
Your answer
Physician's Phone Number (XXX) XXX-XXXX *
Your answer
Health Insurance Provider *
Your answer
Policy or Group Number *
Your answer
Medical Allergies or Concerns (If there are no concerns, please type "none" in the box) *
Your answer
Food Allergies (If there are no concerns, please type "none" in the box) *
Your answer
Emergency Contact Name (First and Last) *
Your answer
Emergency Contact Number (XXX) XXX-XXXX *
Your answer
Emergency Contact Relationship to Child *
TYPING YOUR NAME IN THIS FIELD WILL REPRESENT YOUR SIGNATURE. I, the undersigned parent or legal guardian do hereby authorize and consent to any x-ray examination, medical or surgical diagnosis rendered under the supervision of the medical staff listed under the provisions of the Medical Practice Act and on staff of any acute general hospital currently licensed by the State of California Department of Health. It is understood that this authority is given in advance to any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to the physician in the exercise of his best judgment. It is understood that reasonable effort will be made to contact the undersigned prior to rendering treatment, but that treatment will not be withheld if the undersigned cannot be reached. Medical expenses will be borne by the child's family and/or health insurance. *
Please type your full name below.
Your answer
A copy of your responses will be emailed to the address you provided.
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