VBS Registration/Medical Release

Grace United Methodist Church

SonForce Kids: Special Agents

JUNE 14th - 18th

Vacation Bible School 2010: Registration & Medical Release Form

ONE PER CHILD PLEASE!

Full Name

Birthday Grade Completed

Street Address

City State Zip

Home Phone Cell Phone

E-Mail

Parent's Names

Parent's Work Numbers

In Case of Emergency Contact

Health Insurance Company

Policy or Group Number Phone

Please list any allergies, including medications and foods:

Does your child have any medical or special needs, including medications currently being used? Yes No

If Yes, please explain:

Doctor's Name Phone

Dentist's Name Phone

Date of last tetanus shot

I (we) the parent(s) or guardians of the above listed minor, do hereby authorize adult volunteers of Grace United Methodist Church, Story City, IA as agent(s) for the parent(s) or guardians, 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 Grace United Methodist Church, Story City, IA, 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.

Date

Agree Disagree

T-Shirt Size: Shirt orders must be placed by May 28th to guarantee the size you requested!!

Youth Sizes: Small 6-8 Medium 10-12 Large 14-16

Adult Sizes: Small Medium Large X-Large XXLarge

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Registration & Medical Release