Jacksonburg United Methodist Church 2017 VBS Registration Form
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Child's Name *
Age *
Grade Completed *
Street Address *
City *
State *
Zip *
Home Phone
Cell Phone
E-mail Address
Church Currently Attend
Emergency Contact #1 Name *
Emergency Contact #1 Phone *
Emergency Contact #2 Name
Emergency Contact #2 Phone
Allergies or Special Needs (Including Food)
Medical Conditions
My Child May Be Photographed (Photos May Be Used In Promotional Material For VBS) *
Other Notes Jacksonburg VBS Should Be Aware Of
My Child Is Authorized To Leave With (Please Include ALL Names and Phone Numbers) *
I Plan To Stay At VBS With My Child's Group (Any Parent/Guardian Remaining In Attendance At VBS Must Complete A Background Check, Complying with JUMC's Safe Sanctuary Policy) *
AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR (Will be used only in an emergency and if we are unable to reach the above named person) We, the undersigned parents/guardian of the above noted minor, do herby authorize the vacation bible school workers of Jacksonburg United Methodist Church, as agents of the undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable y or is rendered under the feral or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act 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. *
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