Child's First Name:

Home Address:

Home Phone:

Child's Last Name:

City:

Cell Phone (Mom/Guardian):

School:

Zip:

Cell Phone (Dad):

Phone to Call between 9am-12pm:

Home Church:

Email:

How did you hear about VBS?:

Name & Phone # of people who can pick up your Child:

Allergies::

Medical Concent And Waiver

I, the undersigned parent/legal guardian of (Name of Child)

who was born (Birth Date)

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Do hearby authorize and concent to any X-Ray, examination, anesthetic, medical or surgical diagnosis and treatment and emergency hospital care which is deemed advisable by and is rendered under the general or specific supervision of any member of the medical staff licensed under the provision of the Medical Practice Act and on the staff of any acute general hospital holding a current license to operate from the State of California, Department of Public Health. It is undersigned prior to rendering treatment to the patient, but that none of the treatment will be withheld if the undersigned cannot be reached.

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Further, in consideration of the benefits to be derived from the participation of the minor in the Paradise Evangelical Free Vacation Bible School, the undersigned, to the fullest extent permitted by law and on behalf of both the undersigned and the minor, herby waves, releases, discharges and agrees to indemnify Paradise Evangelical Free Church and its members, employees, volunteers and agents from any and all claims of damages or liability which may hereafter accrue for death, personal injury or property damage which may arise out of participation of the minor in the Paradise Evangelical Free Vacation Bible School.

Signed:

Doctor's Name:

Medical Insurance Co.

Relationship:

Date:

Doctor's Phone #:

Policy Number

Best Emergency Phone #: