CHRIST PRESBYTERIAN CHURCH
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VBS Medical Release Form
If the child you are registering does not have health insurance coverage, please type "none" is the required spaces below.
Indicates required field
Child's Name #2
Child's Name #3
Health Insurance Provider
Policy Holder Name
Insurance Provider Phone Number
Group or Member Number
In the event I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to have my child transported to:
Hospital of Choice
Please read these important disclaimers before proceeding:
*I understand my child will be treated with first aid in an emergency situation and grant my consent for
**By submitting this online form, I hereby grant permission for Christ Presbyterian Church, it’s staff and authorized volunteers, to take photographs and/or video of my child while participating in Vacation Bible School and use them for the following: classroom crafts, online viewing, daily newsletters, and VBS Spotlight video, and to publish the same in print (name withheld), electronic and/or broadcast media, for promotional and informational purposes.
I understand that checking the box below constitutes a legal signature confirming that I acknowledge and agree to the terms above.
Please Type Your First and Last Name
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