Please fill out one form per child to simplify our grouping during VBS. Child's Full Name (required): Male Female Child's Age (required): Date of Birth as YYYY-MM-DD (required): Grade Completed (required): List all Medical Issues (required): List all Allergies (required): List any activity restrictions (required): Street Address: City: State: Zipcode: Parent/Guardian Full Name(s) (required): Parent/Guardian E-Mail (required): Home Phone: Cell Phone (required): Home Church: Emergency Contact Name (required): Emergency Contact Phone(required): The following Medical and Liability Agreement will have to be signed the first night this child attends. Medical and Liability Release: We realize that no activity is without the possibility of unforeseen hazards that could result in injury to an individual. For this reason, St. Paul Presbyterian Church (STPPC) provides supervision and directions for the safe conduct of activities. Sometimes these directions are not followed or are disregarded by children in our programs, resulting in injury. As a parent, or other responsible person, STPPC expects you to be aware of your responsibility to instruct your child of the importance of conduct that will insure safety and an enjoyable time. By signing this form you, as a parent, guardian, or other responsible person, agree to assume the risks and hazards that may be inherent in all activities. You also agree to absolve and hold harmless STPPC and/or its owners, agent, or employees for damage, losses, or injuries to the person(s), or property undersigned. I understand that I am signing for the minor listed on this form and that the signature is both a medical and liability release. If an accident should occur which causes a dispute between STPPC and me; I agree not to press charges in a court of law. In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by STPPC to hospitalize, secure proper treatment, and/or injections, anesthesia, or surgery of my child as deemed necessary. Parent/Guardian Signature and Date will be requested at the registration table. Is your child covered by insurance? Yes No Name of Policy Holder: Insurance Company: Policy #:
Child's Full Name (required): Male Female
Child's Age (required): Date of Birth as YYYY-MM-DD (required):
Grade Completed (required):
List all Medical Issues (required):
List all Allergies (required):
List any activity restrictions (required):
Street Address:
City:
State:
Zipcode:
Parent/Guardian Full Name(s) (required):
Parent/Guardian E-Mail (required):
Home Phone: Cell Phone (required):
Home Church:
Emergency Contact Name (required):
Emergency Contact Phone(required):
The following Medical and Liability Agreement will have to be signed the first night this child attends.
Medical and Liability Release:
We realize that no activity is without the possibility of unforeseen hazards that could result in injury to an individual. For this reason, St. Paul Presbyterian Church (STPPC) provides supervision and directions for the safe conduct of activities. Sometimes these directions are not followed or are disregarded by children in our programs, resulting in injury. As a parent, or other responsible person, STPPC expects you to be aware of your responsibility to instruct your child of the importance of conduct that will insure safety and an enjoyable time. By signing this form you, as a parent, guardian, or other responsible person, agree to assume the risks and hazards that may be inherent in all activities. You also agree to absolve and hold harmless STPPC and/or its owners, agent, or employees for damage, losses, or injuries to the person(s), or property undersigned. I understand that I am signing for the minor listed on this form and that the signature is both a medical and liability release. If an accident should occur which causes a dispute between STPPC and me; I agree not to press charges in a court of law. In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by STPPC to hospitalize, secure proper treatment, and/or injections, anesthesia, or surgery of my child as deemed necessary.
Parent/Guardian Signature and Date will be requested at the registration table.
Is your child covered by insurance? Yes No
Name of Policy Holder:
Insurance Company:
Policy #:
