VBS (Parent)
Parent or Guardian Information
- Please provide parent or guardian information below. Child information will be requested on the next page.
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Parent/Guardian
First Name
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Parent/Guardian
Last Name
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Parent/Guardian
Address
Parent/Guardian
Address 2 (Apt/Suite # etc.)
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Parent/Guardian
City
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Parent/Guardian
State/Province
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Parent/Guardian
Zip/Postal Code
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Parent/Guardian
Email
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Parent/Guardian
Mobile Phone
*Medical Release
- [l) (we) the undersigned. parent(s)/guardian(s) of the registrant(s). a minor, do hereby authorize the adult sponsors or Christian Fellowship Church, as agent(s) for the undersigned, to consent to an examination, anesthetic medical or surgical diagnosis or treatment and hospital care, which is deemed advisable by, and is required to be rendered under the general or special supervision of, any physician or at the hospital or other health care facility. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of the aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which may be determined by a physician or surgeon, as aforesaid, to be advisable in the exercise of his/her best judgement.
* Signature - I HAVE read the Medical Release statement.
* Emergency Contact
* Relationship to Student
* Phone Number
* Phone Type
Select one
Home
Cell
* Hospital Preference
Pickup Authorization
- Children will be released from VBS only to individuals who have the pickup code generated at check-in. This code can be presented via text message or printed pick-up ticket.
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