Thank you for joining us at our Vacation Bible School. Please fill out the following form and then submit when completed.
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Name of Parent or Guardian

 
First name of Parent or Guardian *

 
Last name of Parent or Guardian *

 
Hi {{answer_50277673}}, welcome to our VBS signup.
What's your child's name? *

first & last please
 
What's the age of your child? *

 
What's their date of birth?

 
Does the child have any allergies? *

     
 
If {{answer_50256642}}, what allergies do they have? *

 
Does the child have any medical concerns? *

     
 
If {{answer_50256925}}, please explain further *

 
Would you like to register a second child? *

     
 
What's your second child's name?

first & last please
 
What's the age of your second child? *

 
What's the second child's date of birth?

 
Does the second child have any allergies? *

     
 
If {{answer_50277484}}, what allergies do they have? *

 
Does the second child have any medical concerns? *

     
 
If {{answer_50277490}}, please explain further *

 
Would you like to register a third child? *

     
 
What's your third child's name?

first & last please
 
What's the age of your third child? *

 
What's the third child's date of birth?

 
Does the third child have any allergies? *

     
 
If {{answer_50277577}}, what allergies do they have? *

 
Does the third child have any medical concerns? *

     
 
If {{answer_50277581}}, please explain further *

 
Best phone # to reach you at *

Best phone number to reach parent or guardian at
 
Please provide your mailing address

 
Street

 
City

 
Zip Code

 
In case of an emergency, please provide your medical information

 
Insurance provider *

 
Policy # *

 
Group ID *

 
Name of policy holder *

 
Emergency contact *

name and phone number
 
Photographs of my child may be used (child will not be named if placed on the website) *

     
 
Emergency Medical Care

 
I have read and understand the statement below *

I hereby give permission that my child enrolled at the Kirkland church of Christ VBS may be given emergency treatment by a volunteer. I further authorize and consent to medical, surgical, and hospital care, treatment, and procedures to be performed for my child by a licensed physician, hospital, or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child's heath, and I cannot be contacted. I waive my right of informed consent to such treatment.

I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.
     
 
Any other information you would like to provide?

Thank you {{answer_50256519}}, look forward to meeting you and your child!
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