#1 Childs' Name

Male Female

#1 Childs' Date of Birth

#1 Childs' Grade

#2 Childs' Name

Male Female

#2 Childs' Date of Birth

#2 Childs' Grade

#3 Childs' Name

Male Female

#3 Childs' Date of Birth

#3 Childs' Grade

#4 Childs' Name

Male Female

#4 Childs' Date of Birth

#4 Childs' Grade

Parent/Guardian Name(s)

Home Phone

Cell Phone

Parent Email

Address

City

State

Zip

In case of emergency notify

Emergency Contact Phone #

Medical/Allergy Info Child 1

Medical/Allergy Info Child 2

Medical/Allergy Info Child 3

Medical/Allergy Info Child 4

Dismissal Information - Who may pick up your child at the end of each VBS day?

Other Information - Does your child attend Sunday School? If so where?

If your child is visiting our church, who is he a guest of?

May we have permission to photograph your child? May we have permission to photograph your child? Yes No

May we have permission to use your child's photograph for the purpose of promotion? May we have permission to use your child's photograph for the purpose of promotion? Yes No

LIABILITY RELEASE: In consideration of Holly Springs Baptist Church allowing the above child(ren) to participate in Vacation Bible School activities, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless Holly Springs Baptist Church its directors, employees, volunteers, and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above child(ren) while involved in Vacation Bible School. Furthermore, on behalf of my minor child(ren), I hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in activities involved therein. As well as releasing the child(ren), if necessary, for transportation to and from the Vacation Bible School location, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless Holly Springs Baptist Church, its directors, employees, volunteers, and agents from any and all liability, claims or demands for accidental personal injury in the process of transportation. TYPE NAME OF PARENT/LEGAL GUARDIAN IN THIS FIELD

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) pursuant to this authorization. TYPE NAME OF PARENT/LEGAL GUARDIAN IN THIS FIELD