Vacation Bible School 2014
July 7th-11th 2-5pm
What you need:
□ Registration and Health Form (attached)
□ Payment: $35 per child or $50 per family
□ Medication Form if necessary (upon request)
□ Mark your calendars for July 7th-11th
We would love to have your help! If you have any available time during the week of VBS to help out, let us know!
Bring all forms and payment to church office as soon as possible
to ensure your spot J
Questions: Contact Caitlyn Brennan
Vacation Bible School Registration and Health Form
To be completed by parent or guardian if youth is under 18 years old.
Please type or print clearly.
Youth’s Name: ______
Grade in September:______Age:_____ Birth date:______
School attending:______T-Shirt Size: ______
Address:______
______
Parent(s) or guardian(s) name(s): ______
E-mail:______
Home phone: ______Work phone: ______
Cell phone: ______
Please provide names of persons to contact if parent(s) or guardian(s) cannot be reached.
Name: ______
Phone: ______
Name: ______
Phone: ______
Any reason youth should not participate fully in activities?
______
Will the youth bring any medicine to the activity? If so, please fill out medication form.
If necessary may the youth receive over the counter pain relief during the activity?
No___ Yes___ Parent signature ______
Is the youth allergic to any medicines? If so, please list: ______
______
Other allergies (food, plant, animal, etc.):______
______
Date of youth’s last tetanus shot (Must be within 10 years): __/__/__
Name, address, and telephone number of youth’s doctor:
______
______
Name and account number of medical insurance coverage:
______
Other information we should know: ______
ALL ATTEMPTS WILL BE MADE TO CONTACT THE PARENTS FIRST.
I, the undersigned parent or guardian of (please print name of youth) ______, do hereby authorize bona fide officials of the activity, as agents for the undersigned, consent to x-ray, examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and is to be rendered under the provision of the Medical Practice Act by the medical staff or a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. This authorization shall be in effect for the school year ______to ______, unless revoked by me at an earlier date. A photocopy of this authorization shall be considered as an original (California Civil Service 25.8).
Parent’s Signature______Date: __/__/__
Medication Form (Prescription Medicine Only)
Prescribing Physician:______
Drug: Name______Date filled______
Strength______Quantity______
Dosage______Expiration Date______
Prescription #______#of Refills______
Time to be Administered:______
Special Instructions: ______
______
______
Prescribing Physician:______
Drug: Name______Date filled______
Strength______Quantity______
Dosage______Expiration Date______
Prescription #______#of Refills______
Time to be Administered:______
Special Instructions: ______
______
______
Prescribing Physician:______
Drug: Name______Date filled______
Strength______Quantity______
Dosage______Expiration Date______
Prescription #______#of Refills______
Time to be Administered:______
Special Instructions: ______
______
______