Vacation Church School Registration Form

Vacation Church School Registration Form (2019)
West End Collegiate Church

Child’s Name:_________________________________________________________________
Child’s DATE OF BIRTH:_______/________/________ AGE:______________
GRADE:________________ GENDER: ________________

Primary Parent(s)/Guardian(s) – Please note which guardians will be dropping off and picking
up your child from VCS
Name(s):______________________________________________________________________
Address:______________________________________________________________________
City_________________________ State_______________________ Zip _________________
Home Telephone Number:________________________ Cell: ___________________________
Email:________________________________________________________________________

Secondary Parent(s)/Guardian(s)
Name(s):______________________________________________________________________
Address:______________________________________________________________________
City_________________________ State_______________________ Zip _________________
Home Telephone Number:________________________ Cell: ___________________________
Email:________________________________________________________________________

As a parent or legal guardian, I hereby give permission for my child
___________________________ (Child’s Full Name) to participate in West End Collegiate
Church’s Vacation Church School, August 19-23, 2019.

X____________________________________________
(Signature)

Medical & Personal Information
(All information written below is kept strictly confidential)

1. Does your child have any medical conditions that may affect their participation in VCS that we
should know about? If yes, please describe:
__________________________________________________________________________________
__________________________________________________________________________________
2. Is your child taking any medications that we should know about? If so, please list.
__________________________________________________________________________________
__________________________________________________________________________________
3. Does your child have any dietary restrictions? If so, please list.
__________________________________________________________________________________
__________________________________________________________________________________
4. Is your child allergic to any food or medication? If so, please list.
__________________________________________________________________________________
__________________________________________________________________________________
5. What does your child like to do best? What do they believe they are the best at? Any hobbies?
__________________________________________________________________________________
__________________________________________________________________________________
6. Does your child have a favorite Bible story? Do you?
__________________________________________________________________________________
__________________________________________________________________________________
7. Please list any other information you would like us to know before VCS begins.
__________________________________________________________________________________
__________________________________________________________________________________

I give permission for my child to participate in West End Collegiate Church’s Vacation Church School
programming. I agree not to hold West End Collegiate Church or any of its staff or volunteers liable
for losses, diseases, or injuries incurred by the subjects of this form. I understand that reasonable
precautions will be taken by all leaders at all times. I understand that, in the event my child requires
medical or dental treatment while under the care of WECC staff and/or volunteers, reasonable efforts
will be made to contact me; however, if I cannot be reached, I consent and give permission to those
adults acting on behalf of the church to consent to any x-ray examination, injections, anesthesia,
medical, dental, or surgical diagnosis and treatment, and hospital care and treatment advised and
supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the
state where the services are rendered, either as an outpatient or in any hospital.

Please acknowledge with your signature

Parent/Guardian’s Name (Printed): ______________________________________________________

Parent/Guardian’s Signature:___________________________________________________________