Child Registration Form

Parent/Guardian Information

PLEASE FILL OUT ONE FORM PER CHILD

Check here that you've read.

Today's Date

Parent/Guardian Name(s) (First & Last)

This address will receive a confirmation email

Phone

Please Check for Phone Type

Home Cell Work

Street Address

Relationship to Child

Child Information

Child's Name (First & Last)

Child's Birthday and Age

Child's Grade Just Completed

K 1st 2nd 3rd 4th 5th

Child's Gender

Female Male

Allergies

Yes No

If Yes, please list; If no, write NA

Medical Concerns

Yes No

If Yes, explain; If No, write NA

Child's Medical Provider & Phone Number

Emergency Contact 1 (During VBS)

Emergency Contact Phone

Relationship to Child

Emergency Contact 2 (During VBS)

Emergency Contact 2 Phone

Relationship to Child

Other Information

Do you attend church anywhere? yes no

If yes, where do you attend?

Who may pick up your child at the end of VBS each day?

Their Relationship to Child

Consent for Participation, Medical Treatment & Photo/Media Release

I am the parent or legal guardian of the above named child and I give permission for my child to attend Vacation Bible School at The Mission Church of Lexington and participate in all VBS activities. I authorize all medical, surgical, diagnostic, and hospital care or procedures which may be performed or prescribed for the above named child by a licensed physician or hospital, when efforts to contact me are unsuccessful and when deemed immediately necessary or advisable by the physician to safeguard my child’s health. I acknowledge that The Mission Church of Lexington will not be responsible for medical expenses incurred. I give permission for the above named child to be photographed during VBS, and for the images to be published, reproduced or distributed by The Mission Church of Lexington in all outlets, including, but not limited to, internet and church publications, without liability or limitation on my or my minor’s part.

Parent/Guardian Signature (typing your name will lawfully be your signature)

Child Registration Form

Description

Please Fix the Following