Vacation Bible School

ROCKY RAILWAY VACATION BIBLE SCHOOL REGISTRATION FORM

Grand Junction First Church of the Nazarene 2802 Patterson Rd. Grand Junction, CO

August 3-7, 2020 6:15-8:30 p.m.

One form per child please

Child's First Name*

Child's Last Name*

Today's Date (mm/dd/yyyy)*

Birthdate (mm/dd/yyyy)*

Grade in fall 2020*

Parent or Guardian’s name(s)*

Address

City

State

Zip

Phone Number (Home)*

Phone Number (cell)*

Email*

Emergency Contact Name*

Emergency Contact Phone Number*

Allergy/Special Information

Inhaler

My Child has my permission to carry their own inhaler and knows how to use it correctly.

Person(s) authorized to take child from premises

How did you hear about VBS?

Home church if any

The church named above has my permission to use appropriate group photos on the church website, Facebook page, and on printed promotional materials that may include an image of my child. (No names will be used in conjunction with the photos.)*

Yes

The church named above may take a single picture of my child for use on a take home craft Only.*

Yes

Splitter

Emergency Information and Medical Authorization Parent Consent: The purpose of the following information is 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 any phone numbers listed above have been unsuccessful, I hereby give my consent for:

(1) The administration of any medical treatment deemed necessary by my child’s physician or any other hospital reasonably accessible.

Child's Primary Care Physician

Child's Primary Care Physician's Phone Number

(2) The administration of Grand Junction First Church of the Nazarene to administer first-aid treatment for any minor injuries my child receives during VBS, and if the injury is life threatening to summon any or all professional emergency personnel to attend, transport, and treat my child. I agree to hold harmless any staff, assistants, and volunteer workers of Grand Junction First Church of the Nazarene from any and all claims, suits, costs, and actions of any kind whatsoever, arising from their exercise of the power granted by this authorization. My signature also affirms all the agreements and information above.

Parent or Guardian Signature*

Insurance Company

Policy Number