VBS

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Vacation Bible School (VBS WEEK) (824 S. State Street, Jackson, MS 39201)
Jun 17, 2024 12:00 AM
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Child's Information

First Name *

Last Name *

Date of Birth *

Gender *

Child's T-Shirt Size *

Allergies *

Tip: Please list any specific allergies your child has and if your child has a prescribed EpiPen.

Medical Conditions *

Tip: Please list any mobility issues, special needs or medical conditions. Enter N/A if none.

Are there any Legal or Custody issues we should be aware of? *

If yes, please explain.

Parent/Guardian Information

Full Name *

Mobile Number *

Email Address *

Home Address *

Home City *

Home State *

Home Zip Code *

Medical Release

I, the undersigned parent/guardian, do hereby authorize the CityHeart Church staff as agents for me/us to consent to any x-ray examinations, anesthetic, medical or surgical diagnosis or treatment and hospital care which deemed advisable by and is to be rendered under the general specific supervision of any physician and surgeon licensed under the provisions of the Medical Practices Act. I/we assume all risks and hazards that are incidental to the conduct of these activities. I/we further agree to release, absolve, indemnify, and hold harmless CityHeart Church and the Vacation Bible School leaders of all legal responsibility.

Medical Release *

Parent/Guardian Signature *

Tip: First and last name

Emergency Contact Information *

Tip: Please provide the person’s name and relationship to the child.

Emergency Contact's Phone Number *

Photo Release

I give CityHeart Church permission to photograph my child(ren) and to use his/her image in publications, emails, videos or social media content released by the church (children's name are never attached to photographs).

Photo Release *