Index

Cerro Gordo Community VBS Registration

Child's Name *

First
Last
Child's Birthdate: *

MM 		/
DD 		/
YYYY
Parent's Name (1) *

First
Last
Parent (1) Email:
Please provide your email address for future communications about VBS
Parent's Name (2)

First
Last
Address *

Street Address

Mailing Address

City
State / Province / Region

Postal / Zip Code
Country
Primary Phone Number *

### 		-
### 		-
####
Emergency Phone *

### 		-
### 		-
####
A Secondary Emergency Phone number is required if we cannot contact the Primary Phone.
"Other" Authorized Person for Child Pick Up:

First
Last
Someone other than the parent(s) who will be picking up this child.
Church Affiliation:
 CG Methodist Church 
 CG Church of the Brethren 
 CG Brethren Church 
 LaPlace Church of the Brethren 
 Oakley Brick Church of the Brethren 
 CG Assembly of God 
 Other Church Affiliation 
 No Church Affiliation 

Releases Section

Please carefully read and check the releases below.
Food Allergies:
Please list any foods like "peanuts" that your child cannot have or consume. If more than a few, please bring a complete list on opening day.
Medicines & Special Physical Needs: *
 I Agree and Understand 
I (We) understand that only I (We), as the parent(s), am responsible for the administration of prescription medicines or special physical needs for my child.
Emergency Medical Release: *
 I Give Permission 
 I Do Not Give Permission 
Medical Release: I (We), the parent(s) or guardian(s) of the above listed child grant permission for our child to participate in Vacation Bible School and to receive emergency medical treatment if necessary. If I (we) or the listed child care provider or emergency contact cannot be reached, I (we) give our permission to the staff to secure the services of a licensed physician, ambulance service or medical facility to provide the necessary emergency care.
Photo & Video Release *
 I Give Permission 
 I Do Not Give Permission 
Photo & Video Release: I (We) understand that as a participant in Vacation Bible School that my child may be photographed or videotaped during VBS events. I also understand that these may be used in presentation & promotional materials.
Other Notes from the Parent
Please use this space to type any other information about your child or registration that we need to know.
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Cerro Gordo Vacation Bible School
July 18 - 22, 2011  at Cerro Gordo Methodist Church