Child
Registration

Child's Name *

First Name

Last Name

Parent/Legal Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Child's Birthdate *

MM

DD

YYYY

In case of emergency, whom do we call? *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

I need transportation to and/or from VBS. *

Yes

No

Date Signed *

MM

DD

YYYY

Child's Name *

I, the undersigned parent or legal guardian of the below mentioned child, a minor, do hereby authorize adult volunteers of First Baptist Church as agent(s) for the undersigned 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 First Baptist Church including any of its ministers, leaders or volunteers in the event of an accident enroute, during or returning from the above-mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence.

First Name

Last Name

Date Signed *

MM

DD

YYYY

Parent/Legal Guardian *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Phone (Home) *

(###)

###

####

Emergency Phone (Work) *

(###)

###

####

Does your child have any medical or special needs, including medications currently being used. *

Yes

No

Doctor's Phone Number *

(###)

###

####

Dentist's Phone Number *

(###)

###

####

Date of last tetanus shot *

MM

DD

YYYY