VBS 2017 Registration Form – Living Hope Christian Church

Please fill out a separate form for each child you are registering. Thank you!

VBS 2017 Registration Form

Student's Name *

Parent/Family/Guardian Name *

Address *

Email Address *

Phone Number (Home) *

Phone Number (Cell)

Phone Number (Work)

Child's Date of Birth *

Child's Age *

Last School Grade Completed *

Home Church

Friends of Your Child at This Church

Allergies/Medical Information/Other

Emergency Contact #1 (Name) *

Emergency Contact #1 (Phone) *

Emergency Contact #2 (Name)

Emergency Contact #2 (Phone)

Name(s) of person(s) who may pick up this child from VBS

MEDICAL RELEASE

I (we), the undersigned parent(s) or guardian(s) of (CHILD'S NAME), a minor, do hereby authorize adult volunteers of Living Hope Christian Church as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability Living Hope Christian Church and any of its ministries or leaders in the event of an accident en route, during and returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence. *

Enter Child's Name Here

Health Insurance Company, Policy or Group Number and Phone *

If parent/legal guardian is not available in an emergency, contact this name and phone *

Please list any medical needs including medications currently being used

Doctor's Name and Phone *

Dentist's Name and Phone *

Date of Last Tetanus Shot *

Click "YES" if the information you provided is accurate and you would like to register your child. *

Yes

*A signature is required before your child can attend our VBS. We will have you sign and date this form when we see you. If your child has special needs, please fill out our Special Needs form on the page you will be redirected to when you click "Register." Thank you!

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