VBS 2023 HEALTH FORM

OUTDOOR VACATION BIBLE SCHOOL 2023 Registration
TK - 5th ~ August 7-12, 2022 ~ 8:30am-12pm
One form per child. Child must be 4-yrs of age by July 10, 2023
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

Health Authorization and Release Form

HEALTH AND MEDICAL INFORMATION

Location

Contact us

Mass Schedule

Click here for Mass Schedule

Click below for Fillable
Parish Registration Form

Health Authorization and Release Form

HEALTH AND MEDICAL INFORMATION

Location

Contact us

Mass Schedule

Click here for Mass Schedule

Click below for Fillable Parish ​Registration Form

Click below for Fillable
Parish Registration Form