Third Grade Registration

CAPTCHA
Child's Name (complete an individual form for each child)*
First Last
NOTE: We are limited to 10 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 Last 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
Name
This field is for validation purposes and should be left unchanged.

Vaccinations must be up to date to attend VBS.