Vacation Bible School Registration & Health Form

Vacation Bible School Registration & Health Form

2019 - Please mail payment to: United Methodist Church, PO Box 148, Coon Rapids, IA 50058 . - attn: Mandy Smouse
Personal Information of Camper

First NameLast Name
Gender
Age the week of VBS (June 17th)*
Grade Entering
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name
Parent/Guardian Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Gaurdian Email
example@example.com
Emergancy Contact's Name and Phone Number
Siblings Attending VBS
Siblings Attending VBS
Siblings Attending VBS
General Health Information: Chronic or Recuring Health Issues that may affect VBS
Food Allergies
Dietary Restrictions
Medications (kinds/dosage)
Does the camper have current health insurance? Yes/No and Policy Holder's Name
Dismissal Information: Name(s) of person(s) who may pick up this child from VBS.
I give permission for my child to participate in all aspects of Vacation Bible School except as noted*
I understand that every effort will be made to contact me if my child needs emergency medical treatment*
I authorize medical personnel or VBS staff to secure any medical or emergency treatment as deemed necessary for my child*
I give permission for any picture of my child to be used for promotional and social media purposes*
Parent/Guardian Signature
We ask that you please sign this form the first morning of VBS or print a copy and send with your child the first day.
Date Completed

MonthDayYear
Date
Type a question
Type a question
I am interested in a scholarship for my child(ren) to attend
This information is all kept confidential.
Please include any other information you may feel might be useful to those spending the mornings with your child(ren) during VBS week: