Please - One Child Per Form

 Parents/Guardians

Parent/Guardian Name:

Address:

Email Address:

Phone Number:

Cell Number:

Child Information

Child's Name:

Child's Grade (4yrs to graduating 5th graders):

Child's Date of Birth:

Child's Sex:

_________________________________________________

Emergency Contact1 Name & Relationship To Child:

Emergency Number1:

Emergency Contact2 Name & Relationship To Child:

Emergency Number2:

List allergies or medical conditions:

List siblings that will also be attending:

Indicate below if help with transportation is needed:

List below any special friends your child would like to be with:

_________________________________________________

Please indicate areas you would like to help with (if applicable) or any other notes here:

Childcare is provided for the children of the volunteer workers only!

Indicate the age(s) of the child(ren) needing childcare:

By clicking 'send' I give permission for my child to participate in the VBS-2010 activity and release FBC-Coldwater, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage o property.  In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the director of children's ministry to make and perform the decision that they deem necessary.