Vbs Consent Form printable pdf download

VBS CONSENT FORM

Name of child __________________________________________________________________

Name of parent(s) or guardian(s) ___________________________________________________

Address_______________________________________________________________________

Home telephone______________________ Cell phone_________________________________

In case of an emergency when a parent cannot be reached please call:

Name, Relationship____________________________________ Phone____________________

Name, Relationship ____________________________________ Phone____________________

Medical Information

Is your child presently being treated for an injury or sickness or taking any medication?

Yes________ No________If yes, please explain.______________________________________

Does your child have a physical handicap or illness that would prevent him or her from

participating in normal activities? Yes______ No______ If yes, please explain.______________

______________________________________________________________________________

Does your child have an speciﬁc food or medical allergies? Yes_____ No______ If yes, please

specify._______________________________________________________________________

Consent and Certiﬁcation

_____________________________________________________________________________

(Print Parent Name)

I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the

participation of my child in the activities of Vacation Bible School conducted by Pace Church of Christ. I

certify that my child is physically ﬁt and adequately prepared to participate in this event.

Medical Treatment Authorization

I understand that I will be notiﬁed in the case of a medical emergency. However, in the event that I cannot

be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event

that my child is injured or becomes ill. I authorize the adults chaperones of Pace Church of Christ to make

emergency medical care decisions on behalf of my child, if required by law or a health care provider.. I

authorize these persons to act in my place to consent to all necessary and appropriate x-ray

examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care.

I understand that Pace Church of Christ will not be responsible for medical expenses incurred solely on

the basis of this authorization. I also understand that the designated adult chaperones reserve the right to

restrict my child from any activity that they do not feel is within the physical capabilities of my child.

___________________________________________________ _________________________

Signature of Parent or Guardian

Date

Vbs Consent Form