VBS

VBS

AGES 4-12 JULY 24-26, WED-THURS 7PM-9:30PM, FRI 7PM-10PM, SPECIAL SUNDAY VBS SERVICE JULY 28, 2019 11AM.
Parent/Guardian Name(s) *

First Name Last Name
First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Email
example@example.com
Name of Child *

First Name Last Name
DOB *

Month Day Year
Date Date Picker Icon
Name of Child

First Name Last Name
DOB

Month Day Year
Date Date Picker Icon
Name of Child

First Name Last Name
DOB

Month Day Year
Date Date Picker Icon
Allergies or Medical Concerns *
How did you hear about our VBS?
Home Church
Emergency Information and Medical Authorization
Purpose of the following information: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under church authority, when parents or guardians cannot be reached.
In the event reasonable attempts to contact me at the number below have been unsuccessful, I hereby give consent for: (1) The administrtian of any medical treatment deemed necessary by the (physican) below.
Your preferred contact number *

Area Code Phone Number
Doctor's Name *

First Name Last Name
Doctor's Phone Number *

Area Code Phone Number
In the event the desginated preferred practioner is not available, by another licensed physician or densits; and (2) the transfer of the child to my preferred or any other hospital reasonably accessible.
Name of preferred hospital
Facts concerning the child's medical history including allergies, medications being taken and any physical impairments to which a physician should be alerted: *
Do you give consent for church authorities to contact any medical professionals in the event of an emergency? *

Yes No
Photo/Video Permission
My child may be photographed during VBS and his/her image may be shared on our church website, church social media pages, and/or put into a CD or picture format. *

Yes No
Registration costs is $15 per child. Please keep a copy of your payment receipt to bring with you. It would be most efficient if you complete your payment online.

Please use the link below for your payment and select "Sunday School" in the "fund" field and reference the name(s) of your child in the comments field.

https://powh.givingfire.com/
Did you complete your payment? *

Yes No Will pay cash at the door
Signature *

Clear
DateTime
Should be Empty:

VBS

Emergency Information and Medical Authorization