Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Person(s) authorized to pick up children (besides parents)

First Name

Last Name

Child #1 Name *

First Name

Last Name

Child #1 birthday *

MM

DD

YYYY

Child #2 Name

First Name

Last Name

Child #2 birthday

MM

DD

YYYY

Child #3 Name

First Name

Last Name

Child #3 birthday

MM

DD

YYYY

Name of Doctor *

First Name

Last Name

Medical release/waiver *

I (we), the undersigned parent(s) or legal guardian(s) of the minor child(ren) listed on this form, certify that they have my full approval to participate in Singing Hills Christian Church Vacation Bible School, from July 21, 2019 to July 25, 2019. Further, I hereby authorize the Church's Children Directors or volunteers and adult supervisors of SHCC as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by accredited physician or surgeon, in an approved emergency clinic or hospital, to obtain any necessary medical assistance needed in case of accident or injury to the child(ren). I understand that every effort will be made to contact me. I also understand that the insurance information provided above will be used in any such emergency, and I agree to assume full financial responsibility for any expense incurred for said treatment. I hereby release SHCC, it's employees and agents, including, but not limited to, its volunteers and adult supervisors, from any liability and all legal and financial responsibility, I also agree to indemnify the church, its employees and agents, including, but not limited to its volunteers and adult supervisors, against any other claims by any other parties arising from the child(ren)'s participation in this activity. **BY REGISTERING, YOU ARE ACCEPTING THE TERMS OF THE MEDICAL RELEASE AS WELL AS GIVING SHCC PERMISSION TO USE VIDEO AND PHOTOS THAT INCLUDE YOUR CHILD(REN) TO PROMOTE VBS AND SHCC**

I ACCEPT ALL TERMS LISTED ABOVE AS THE LEGAL GUARDIAN FOR THE CHILD(REN) LISTED ABOVE