VBS Kindergarten - Bible School - Stepney Baptist Church

CAPTCHA
Child's Name (complete an individual form for each child)*
First Last
NOTE: We are limited to 8 children for this event. We will close registration once we are at capacity. Thanks!
Date of Birth*
MM slash DD slash YYYY
Food Allergies
- Gluten
- Dairy
- Egg
- Peanut
- Tree Nuts
- Other
Other Allergies
Other Dietary Concerns
Tetanus Shot*
Date of Tetanus Shot
MM slash DD slash YYYY
Vaccinations must be up to date to attend VBS.

Physician Name*
First Last
Physician Phone*
Hospital Preference*
Health Insurance Company*
Policy/ID Number*
Authorization Form
"I/we the undersigned parent[s] or guardian[s] do hereby authorize adult volunteers of Stepney Baptist Church, in case of any injury that is not serious enough for a hospital, to administer medical aid or CPR by a Certified Adult Leader. In the case of an emergency, I give the adult leaders of Stepney Baptist Church as agent[s] of the undersigned, to take my child/children by ambulance and to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from all liabilities Stepney Baptist Church and any of its ministers or volunteer leaders while my child/children are attending Vacation Bible School during July 24-28, 2017."
Parent/Guardian Name*
First Last
Authorized Electronic Signature*
Date Signed*
MM slash DD slash YYYY
Photograph Permission
I give permission for my child/children to be photographed and used in the closing assembly slide show.
Authorized Electronic Signature
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Name
This field is for validation purposes and should be left unchanged.

Vaccinations must be up to date to attend VBS.