First Congregational Church of Griswold
VBS 2008 Permission Slip & Medical Release Form
Please Print.
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Child’s Name: |
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Child’s Date of Birth: |
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Street Address: |
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City, State, and Zip Code: |
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Parent(s) or Guardian(s): |
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Parent/Guardian Address: (if different from child) |
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Home Phone Number: |
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| Work/Cell Phone Number: | |
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Grade Entering in the Fall: |
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If your child is not school age: is your child potty trained? |
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has your child had any nursery school experience? |
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Emergency Contact Information (in the event Parent/Guardian cannot be reached):
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Emergency Contact's Name: |
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Street Address: |
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City, State, and Zip Code: |
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Home Phone Number: |
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| Work/Cell Phone Number: |
Medical Information:
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Does your child have health insurance? |
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Name of Insurance Company: |
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Policy Number: |
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Group Number: |
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In whose name is the insurance? |
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Child’s Family Doctor: |
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Doctor’s Phone Number: |
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Preferred Hospital: |
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Please list & explain any medical conditions: such as: allergies, diabetes, asthma, physical/emotional/behavioral disability, seizure disorders, etc. |
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Please list any appliances your child uses such as: glasses, contacts, retainers, etc.
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Name, dosage, and frequency of any medications that must be taken: |
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I understand that in the event medical intervention is needed, every attempt will be made to contact the persons listed on this form immediately. In the event I cannot be reached in an emergency during the activities shown on this form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.
I understand that my insurance coverage for my child will be used as primary coverage in the event medical attention is needed. Coverage by First Congregational Church through its accident policy will be used as a backup for what my family’s insurance does not cover.
I understand all reasonable safety precautions will be taken at all times by First Congregational Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold First Congregational Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
Photography:
□ I give permission to First Congregational Church of Griswold to send photographs taken of my child during Vacation Bible School to The Usry Family in conjunction with the Box Project mission.
□ I give permission to First Congregational Church of Griswold to use photographs taken of my child during Vacation Bible School in the monthly church newsletter.
□ I give permission to First Congregational Church of Griswold to use photographs taken of my child during Vacation Bible School on the church website.
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Parent/Guardian Signature: |
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Date: |
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Please mail registration form and payment of $15 per child (or $25 per family) to:
First Congregational Church of Griswold – VBS
878 Voluntown Road
Griswold, CT 06351
Register by June 8th and save $5 off the child or family rate! Scholarships available upon request.