VBS Program Form

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					                        THOMPSON MEMORIAL PRESBYTERIAN CHURCH

                         Vacation Bible School Program Registration Form



Student / Participant

Name:______________________________ Date of Birth:____________ Age:_______
Street Address:__________________________________________________________
City:_________________________ State:_____ Zip:________ Phone:_____________
Grade (fall 2009):________________ School:__________________________________
Sibling names:___________________________________________________________
Academic Strengths/ Needs:_______________________________________________



Parent / Guardian

Mother Full Name:________________________________ Email:__________________
Street Address:_______________________________________      Same as Student
City:______________________ State:_____ Zip:_______ Home Phone:_____________________
Work Phone:____________________________ Cell Phone:______________________________

Father Full Name:________________________________ Email:__________________
Street Address:_______________________________________      Same as Student
City:______________________ State:_____ Zip:_______ Home Phone:_____________________
Work Phone:____________________________ Cell Phone:______________________________

** Important custodial information regarding student:_________________________________**


Publication Permission

In the course of our classes, events pictures and videos are often taken. My child’s likeness may be used
for the following purposes. (Please initial on each to give your permission)
_____ Website ____ Newspaper ____In-church Display ____



Alternate persons authorized to pick up my student from church activity:

Name:___________________ Relationship:_____________ Phone:____________ / _____________
Name:___________________ Relationship:_____________ Phone:____________ / _____________
Name:___________________ Relationship:_____________ Phone:____________ / _____________
                     THOMPSON MEMORIAL PRESBYTERIAN CHURCH

                          Vacation Bible School Program Medical Form


Student / Participant Name:________________________________________________
Insurance Carrier:__________________________ Policy Number:________________
Preferred Hospital:_______________________________________________________
Primary Physician:__________________________ Office Phone:_________________
Allergies:_______________________________________________________________
Medications:____________________________________________________________
Special Needs & Medical Considerations:____________________________________
_______________________________________________________________________

I being the Parent/Guardian of_____________________________, hereby authorize the adult
leader to administer the following designate medications:
___ Acetaminophen __ Ibuprofen ___ Antihistamine ___Antacid ___Antibiotic Ointment
**(Please initial for each medication you are allowing)**

If your child needs to be administered medications during camp hours, please speak to the
director for additional forms that are required.

Emergency Contact information:

Please list those who are authorized to make decisions for you regarding your child if you
cannot be reached.

Name: ____________________________ Relathionship:________________________
Home Phone:_______________ Work Phone:_______________ Cell:_______________

Name: ____________________________ Relathionship:________________________
Home Phone:_______________ Work Phone:_______________ Cell:_______________


Parent / Guardian Consent to Treat and Hold Harmless

I hereby give my permission for myself or my child to participate in an activity organized by
Thompson Memorial Presbyterian Church. I hereby release, hold harmless and absolve TMPC,
their officers, staff, sponsors, vendors, and all others who have participated in the planning,
organizing and implementing of the activity, be they individuals or organizations, singly or
collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or
inconvenience suffered or sustained as a result of the participation in the activity.
I understand that in the event I or my child requires medical treatment while engaged in the
activity, reasonable efforts will be made to contact my designated emergency contacts; however,
if they cannot be reached, I hereby consent and give my permission for TMPC staff or any adult
leader acting on behalf of TMPC with respect to the activity to consent to emergency medical,
dental or hospital treatment.

This medical information form is correct and I am responsible to update it as appropriate.
Signature of Parent/Guardian:____________________________________ Date:_________

				
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