REGISTRATION FORM AUGUST 14-18, 2017.
* means a selection or input required

Today's date* :
  

Child's First & Last Name* :
  

Child's Full Address*:

Cross Streets*:

Date of Birth*:

Gender*:

STUDENT MEDICAL RELEASE FORM.

State Any Medical Conditions*

Asthma?*:

If Yes, will child carry and administer his/her own Asthma Pump?:

Food/Drug Allergies*:

If Yes,name any Food/Drug Allergies:

Routine Medications?*:

Will child carry and administer any routine medications?*:

If Yes, name the Routine Medications:

OTHER INSTRUCTIONS.
 
*I understand that various photographs may be taken by the VBS staff during this program. I give my permission for
the child's picture to be used at the discretion of the program staff.
I also grant permission for the child to walk for lunch at a nearby public school under close supervision of the VBS staff members.
YES or NO*:

Parent's Name*:

Parent's Email*:

Today's date* :

*Please Complete all information below Authorization for Emergency Medical Attention.
 
*I, who by law may do so, authorize the administration of emergency medical treatment for the subject of this release form. I understand that all reasonable safety precautions will be taken at all times. The UPPER ROOM OF PRAYER Inc, or it's agents will not be liable for any accident, injury or disease incurred by the subject of this form. I understand that, in the event medical intervention is needed, every attempt will be made to contact the person(s) listed on this form immediately.
 
Print Parent or Legal Guardian's Full Name:

Cell Phone:

Work Phone:

Person to be contacted in case of Emergency other than parents.
Name:

Relationship to Child:

Cell Phone:

Home Phone:

Your email address will not be published. Required fields are marked *

*