University Christian Church

Vacation Bible School 2008

University Christian Church

Registration and Parental Consent Form

July 21-25 6 pm - 9 pm

Name:_ Age: Birth Date:

Address: Phone: ( )

City: State: Zip: Sex: M F

School: Grade :

T-Shirt Size: (youth) S M L (adult) SM L XL

Parent(s)/Guardian Name: Cell phone:

Cell phone:

E-mail Address: Home Church:

Adult(s) authorized to pick-up my child: 1. 2.

How did you hear About VBS? (check one) Member Yard Sign Invited by friend Other

To whom it may concern:

I, the undersigned parent of , give permission for my child to

attend and participate in Vacation Bible School sponsored by University Christian Church from July 21, thru

July 25, 2008. I authorize an adult, in whose care my minor child has been entrusted, to consent to any X-ray

examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to

my minor child under the general or special supervision and on the advice of any physician or dentist licensed

under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such

diagnosis or treatment is rendered at the office of said physician or at said hospital.

I will be liable and agree (s) to pay all costs and expenses incurred in connection with such medical and

dental services rendered to my minor child pursuant to this authorization.

I also give permission for my minor child to ride in any vehicle designated by the adult in whose care

the minor has been entrusted while attending and participating in activities sponsored by University Christian

Church.

Agree Disagree Parent/Guardian NameDate

Family Doctor: Phone: ( )

Hospital Insurance: Yes No Insurance Plan Name

Insured’s Name Policy/Group Number

Emergency Phone Number ( )

Please list any allergies or special medical problems your child may have below.