VBS REGISTRATION FORM 2019

June 17-21 from 9:00 - 11:30 am

Parent or Guardian Name *
Parent or Guardian Name
Address *
Address
Please Add Me To The Children's Mailing List
I acknowledge there is no cost. *
In the event my child(ren) listed here becomes ill or sustains an injury while on an authorized and chaperoned outing from Salem First Church of the Nazarene, I the undersigned, give my permission to those in charge to take whatever steps are necessary to stop any bleeding and to administer first aid. I also consent to an x-ray, examination, anesthetics, medical, dental or surgical diagnosis, treatment and hospital care, and the administration of drugs, under the specialized supervision upon the advice of a duly licensed physician and/or surgeon. I understand that this consent will apply to all emergency situations present and future, and that a copy of this form is as valid as the original. This consent is to remain effective until written revocation is made. I understand that I am financially responsible for any and all medical /dental services performed on my child.
Alternative Emergency Contact
Alternative Emergency Contact
Family Doctor
Family Doctor
Child's Name #1
Child's Name #1
Date of birth
Date of birth
Child's Name #2
Child's Name #2
Date of birth
Date of birth
Child's Name #3
Child's Name #3
Date of birth
Date of birth
Child's Name #4
Child's Name #4
Date of birth
Date of birth
Media Consent: *
As your child(ren) attends VBS we will try to capture the incredible times we have as a group in photo and video form, which could be viewed/displayed at the church, on slide shows, church publications and/or on the Salem First website and/or social media. If a child’s image is used, these are the guidelines we follow: - Only first names will be used if referencing a child. - Personal information about the child will not be published. - Documents will not include information that indicates the future physical location of a child at a given time other than attendance at Salem First or participation in an activity. By clicking the yes box, you consent for the church to use pictures of your child(ren).