CHRIST PRESBYTERIAN CHURCH
Vision & Values
Medical Release Form
Church Directory Update
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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