Microsoft Word - VBS Child Registration Form 2012.doc



11303039370Sts. Constantine & Helen Greek Orthodox ChurchVacation Bible School Child Registration FormMonday, July 14th –Friday, July 18th9:00 am – 2:00 pm, Ages 4–12 yearsRegistration fee: $50.00*Child’s Name (One Form Per Child):Date of Birth: Age: Grade Entering: Parent/Guardian Name(s): Address: City: State: Zip: Phone #: Secondary Phone #: Email Address: EmergencyContact Name: Phone #: Howdid you hear aboutVBS:Home Church: Allergies or Medical Concerns: EMERGENCY INFORMATION AND MEDICAL AUTHORIZATIONPurpose of the following information: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under church authority, when parents or guardians cannot be reached.In the event reasonable attempts to contact me at (phone #)have been unsuccessful, I hereby give my consent for: (1) The administration of any medical treatment deemed necessary by (physician)Dr. at phone # or (Dentist) `Dr. at phone# , or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to (preferred hospital) or any other hospital reasonably accessible.Facts concerning the child’s medical history including allergies, medications being taken and any physical impairments to which a physician should be alerted:______________________________________________________________________________________________________________________________________________________________________________________________________________2889253746500I do not give consent for church authorities to contact any medical professionals in the event of an emergency. Parent/Guardian Signature:Date? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?23812570485*Please turn in registration forms to the church office, located at 2160 Wauwatosa Ave, Wauwatosa, WI 53213. All fees must be turned with the registration form. Should extenuating circumstances arise, please feel free to contact Ms. Lorice Ratas at (262) 893-8242 to discuss a payment plan. Please make checks payable to Sts. Constantine & Helen Greek Orthodox Church.00*Please turn in registration forms to the church office, located at 2160 Wauwatosa Ave, Wauwatosa, WI 53213. All fees must be turned with the registration form. Should extenuating circumstances arise, please feel free to contact Ms. Lorice Ratas at (262) 893-8242 to discuss a payment plan. Please make checks payable to Sts. Constantine & Helen Greek Orthodox Church. ................
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