Vacation Bible School / Mother's Day Out Summer Program 2019
Questions? Please contact the Church office at 281-342-8664.
Registration and Contacts
Please select a registration type and provide basic contact information.
This Registration is for: *
Parent or Guardian's Name *
Your answer
Address *
Your answer
Primary Contact Phone *
Your answer
Work Phone
Your answer
E-mail Address *
Your answer
Child's Information
Please tell us about your child and share any special requirements.
Child's Name *
Your answer
Date of Birth *
Your answer
Entering Grade (Fall of 2019)
Name of Child's Church
Your answer
Allergies or concerns?
Your answer
Publicity Release
I hereby give permission to First Baptist Church to photograph my child/children during MDO/VBS summer program for viewing with families, friends and the general public. Names of children do not appear with their picture.
Publicity release acceptance: *
Photos of my child/children may be used for
Premise Release
I hereby give permission for the child listed in this registration to participate in all activities. In addition, my child/children has permission to leave school/church with the following individuals (please enter name and phone # for each contact on separate lines)
Your answer
Emergency Contact
Contact in case of an emergency when parents cannot be reached:
Contact Name
Your answer
Contact Phone
Your answer
Contact Address
Your answer
Contact Relationship to Child
Your answer
Medical Contact
I hereby agree that in case of illness or accident requiring a physician's immediate attention, and if I cannot be contacted by the school/church, the following physician may be contacted and is authorized to treat my child.
Doctor's Name
Your answer
Doctor's Phone
Your answer
Doctor's Address
Your answer
Insurance Information
If the above doctor cannot be reached, I give permission for a doctor designated by the program to administer treatment at my expense. I understand and accept the policies above and release the school/church from liability for injury or
illness resulting under all circumstances save gross negligence.
Insurance Provider Name
Your answer
Insurance Provider Phone
Your answer
Insurance ID # or Group #
Your answer
Authorization
Please type your name to digitally sign this form and authorization.
Your Name
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service