VBS Registration 2016
Email
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Name of Child
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Last
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Name of Parent/Guardian
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Phone Number
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-
Area Code
Phone Number
Address
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Address Line 2
City
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Birthday
*
Age
*
Grade Entering
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I understand if my child is attending the 2-3 year olds class I must attend the Adult Class.
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Yes
Gender
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Male
Female
Name of Church Attended
Emergency Contact
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Relationship of Emergency Contact
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Emergency Phone Number (Cell)
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Emergency Phone Number (Home)
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Do you have medical insurance
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Yes
No
Name of Insurance Provider
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Policy Number
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Group Number
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Name of the Insured
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Family Doctor
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Phone Number of Doctors office
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Pre-existing or current Medical Conditions
Name and Dosage of current Medications
Any allergies (food, medications, etc)
Additional information a Dr. should know
E-mail
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I, the undersigned parent or guardian, hereby consent to my child participating on First Baptist Community Church VBS an event sponsored by First Baptist Community Church of Los Gatos from July 25th-July 29th. I certify that my child is able to participate in these activities including, games, crafts , and eating. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize Pastor Daniel or his agents to make emergency medical decisions for my child. If there are any activities I do not want my child to be involved in, I have listed them below. I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITY, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold First Baptist Community Church of Los Gatos and its agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of California, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto, and the terms of this release are contractual and not a mere recital. I further stat that I HAVE CAREFULLY READ THE FORGOING RELEASE AND KNOW THE CONTENTS THEREOF, AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand. I also allow First Baptist Community Church to use my child's image in their publications. By entering my name below I am agreeing to abide by the above release of liability statement. I also realize that my medical insurance provider will be billed for medical charges in the case of illness or injury.
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