Child's Name (first & last)

Gender Gender Male Female

Birthdate (MM/DD/YYYY)

Current Grade Current GradeKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade

Street Address

City, State, Zip

Parents/Guardian

Email Address

Phone Number

Name of Home Church

Emergency Contact

Relationship to Child

Emergency Contact Phone Number

Food Allergies Food Allergies Yes No

Explain

Medical Concerns Medical Concerns Yes No

Explain

Photo Release Photo Release I give permission for my child's name, photograph, or video to be used for school-related public media. I do not give permission for my child's name, photograph, or video to be used for school-related public media. (Student will still be allowed to attend the activity, program, or event.)

Parent/Guardian Consent Parent/Guardian Consent I give consent for my child to attend Redeemer VBS and to be under the care and supervision of VBS staff. I authorize staff members to administer minor medical treatment (ex: of minor cuts and scrapes) to my child while he or she is under the staff's care at VBS.) If I cannot be contacted, I authorize emergency medical treatment to be administered by trained medical personnel (ex: first responders, hospital emergency room staff) in case of my child's severe injury or illness.

Questions or Concerns (optional)