Vacation Bible Camp

Child's Information*

FirstLast

Address*

Street AddressCityStateZip Code

Age (Open to Pre-K – 6th Graders)*

Please enter a value between 5 and 12.

Grade Level

Date of Birth*

T-shirt Size*

Breakfast is served until 9:00 a.m. each day. Select all days that apply.

Monday
Tuesday
Wednesday

BEHAVIOR INFORMATION

Does your child exhibit any behavior of which staff should be aware? (i.e., fears or tantrums).

Yes
No

If so, what suggestions would help the staff effectively deal with behavior?

List any activities to be restricted:

Medical Information

Please list any allergies or medical conditions your child may have.

Current Medication

Include Instructions if medicine is to be administered at camp:

Medication

Dosage

Time:

Doctor's Name:

Doctor's Phone:

Dentist's Name:

Dentist's Phone:

Which over-the-counter medications will you allow the Camp Director to adminster to your child as needed?

Tylenol
Ibuprofen
Benadryl
Mylanta

Special dietary needs

Parent(s)/Guardian Information

MOTHER/GUARDIAN*

FirstLast

Email

Home Phone

Work Phone

Cell Phone

Address (If different from child's)

Street AddressCityStateZip Code

FATHER/GUARDIAN*

FirstLast

Email

Home Phone

Work Phone

Cell Phone

Address (If different from above)

Street AddressCityStateZip Code

If parent/legal guardian is not available in an emergency, contact:*

Please provide name, relationship and phone number.

PICK UP AUTHORIZATION – please provide name, relationship and phone number

(Picture ID must be presented when picking up a child). My child can only be released to the above person(s) without additional consent from a parent or guardian.

Camp Policy and Parent's/Guardians Authorizations:

I understand that the children I am registering, while participating in the West End Church of Christ Vacation Bible Camp, will be expected to follow a code of conduct requiring respect for rules, staff, volunteers, other persons, and property. I grant permission for photographs of my child to be used for camp advertising. I grant permission to Camp Director and Staff to adminster minor medical emergency aid or treatment which they deem appropriate for my child. I hereby give permission to the medical professional(s) selected by West End Church of Christ VBC to order X-rays, routine tests and treatment for the health of my child, and in the event I cannot be reached in an emergency. I hereby authorize and permit said minor to participate in the camp and hereby waive and release all claims for damage and loss to person property of said minor and/or the undersigned which may be caused by any act of failure to act, of West End Church of Christ VBS Camp, its elders, deacons, ministers, volunteers or employees, and assume all risk of possible injury and damage which may result on account of such participation.

Name of person completing this form.*

Authorization:*

I have read and agree to the above terms and conditions:

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Vacation Bible Camp

VBC REGISTRATION FORM

BEHAVIOR INFORMATION

Medical Information

Current Medication

Parent(s)/Guardian Information

Camp Policy and Parent's/Guardians Authorizations:

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