Vacation Bible School!

PARENT(S)/GUARDIANS(S):
Primary Parent(s)/Guardian(s):*
Additional Parent(s)/Guardian(s):

ADDRESS:
Street:*
City:* Zip:*

PHONE:
Home:* Work:
Cell (Preferred): Cell (Alternate):

E-MAIL:
Preferred e-mail address:*
Alternate e-mail address:

If you wish to register more than 3 children, please enter their registration information in the Additional Information box at the bottom of this form.

Volunteer Name:
 Small Group Guide Small Group Guide
 Snack Snack
 Music Music
 Games Games
 Preschool Preschool
 As a volunteer, I will need nursery care As a volunteer, I will need nursery care

VBS +plus+ child name(s):
1.
2.
3.

If you wish to register more than 3 children, please enter their registration information in the Additional Information box at the bottom of this form.

This medical release form pertains to all on or off-site events of Zumbro Lutheran youth and education programs.

• My child has permission to take part in all congregational activities, including off-site activities, and be included in photographs taken for church use only.
• In case of emergency, every effort will be made to contact me. If I cannot be reached, this document gives permission to Zumbro Lutheran Church, its staff, chaperones and supervisory personnel to act on my behalf in seeking emergency treatment for my child.
• I give permission to those administering emergency treatment to do so using necessary measures, and we agree that the congregation, its staff, chaperones, and off-site location personnel will not be held responsible for accidents or liabilities which may occur.

Type initials here, if you agree to the above terms.

FAMILY INSURANCE COMPANY:
POLICY #:

Emergency Contact person (if parents/guardians are unavailable):

NAME:
RELATIONSHIP:
HOME PHONE: CELL PHONE:

Please list any medical history/concerns, prescription medications, allergies, penicillin or other drug reactions, etc.:

If you have medical information for more than 3 children, please enter it in the Additional Information box below.

Please add any additional information we should know about your child here: