Our Lady of Guadalupe Parish, Fremont, CA
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VBS 2022 HEALTH FORM
2022-2023 FF Registration
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Our Lady of Gudalupe Parish Faith Formation Office
40374 Fremont Blvd., Fremont CA
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
REGISTRATION STARTS MONDAY JUNE 5 TILL JULY 15, 2022
MAX. CAPACITY 60 KIDS
*
Indicates required field
Student Name
*
First
Last
Name must be Legal Name
Address
*
Address2
*
City
*
State
*
ZIP
*
Date of Birth
*
School Attending in the Fall 2021
*
Grade
*
Parents Information
Mother Name
*
First
Last
Cell Number
*
Address
*
City/State/Zip
*
Father Name
*
First
Last
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Cell Number
*
Address
*
City/State/Zip
*
Valid Email:
*
one valid email can be communicated
FEE INFORMATION
*
Please choose one
1ST CHILD $60
Each additional Child(same family): $50
3rd Child & + ($180 per family)
T-SHIRT SIZE
*
Please choose one
S
M
L
PAYMENT METHOD
*
Please choose one
Credit Card by phone
Check by mail
Check - pay at the Faith Formation Office
Cash - pay at the Faith Formation Office
Tuition includes: Snacks & T-shirt
ALL PAYMENTS DUE BY JULY 15, 2022
YOU CAN CALL 510-651-4966 FAITH FORMATION TO PAY BY CREDIT CARD OR
MAIL THE CHECK TO FAITH FORMATION OFFICE, 40374 FREMONT BLVD., FREMONT CA
Health Authorization and Release Form
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 had difficulty with the following:
*
Please choose WHICH APPLY
none
Asthma
Fainting
Spells
Convulsions
Diabetes
Heart
Eyes
Ears
Nose
Throat
Lungs
Digestion
Special Needs
Other concern not in the list:
*
Allergy or reaction to any Medication or Food?
*
Yes
No
If yes: please list the medication or food
*
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 Registration
