VBS 2022 HEALTH FORM

OUTDOOR VACATION BIBLE SCHOOL 2022 Registration
K - 6th ~ August 8-12, 2022 ~ 8:30am-12pm
One form per child. Child must be 4-yrs of age by July 2022
MAX. CAPACITY 60 KIDS

Health Authorization and Release Form

* Indicates required field

Name & Cell No - Authorized to pick up child(ren) *

Name & Cell No. - IN CASE OF EMERGENCY, NOTIFY PERSON OTHER THAN PARENT/GUARDIAN: *

HEALTH AND MEDICAL INFORMATION

FAMILY PHYSICIAN: *

ADDRESS *

PHONE *

MEDICAL PLAN: *

PLAN NUMBER *

Do you authorize the Director of Faith Formation or their authorized representative to authorize medical treatment for your child in an emergency, as considered necessary by the attending physician?

Choose One *

Yes NO

State any reason why you do not want medical care given to your child in an emergency: *

List all conditions (such as allergies, seizures) for which your child requires ongoing medication and state the type & frequency of medication given: *

List any physical restriction or restriction for any activity on the basis of medical condition: *

State the date of your child's last physical examination: *

Has your child currently in any physical difficulty, please specify: *

If yes: please list the medication or food *

Allergy or reaction to any Medication or Food? *

Yes No

Other concern not in the list: *

I GIVEN CONSENT FOR ANY PICTURES TAKEN OF MY CHILD'S DURING VBS TO BE PUBLISHED FOR OUR LADY OF GUADALUPE PARISH FAITH FORMATION PURPOSE ONLY.

PARENT/GUARDIAN NAME TO CONSENT *

DATE *

Submit