Our Lady of Guadalupe Parish, Fremont, CA
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VBS 2022 HEALTH FORM
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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:
*
please state N/A if there is no medication needed
List any physical restriction or restriction for any activity on the basis of medical condition:
*
please state N/A if there is no restriction
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
