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Child's Name *

Child's Age *

Child's Gender

Male
Female

Medical Information

If your child has any medical conditions that we should be aware of, or if your child will need to take any medications while at VBS please list them above.

Allergies

Please list any allergies that your child may have, especially food allergies.

Emergency Contact Name *

Emergency Contact Phone # *

Emergency Contact's Relationship to Child *

Liability Release *

I give permission for my child to attend Vacation Bible School at River Valley Bible Church. I understand that personal injury can and may occur to my child, and I hereby authorize the staff and volunteers of River Valley Bible Church to seek and consent to emergency medical attention for my child as needed; and I further agree to be liable for and to pay all costs incurred in connection with such medical attention. I hereby release River Valley Bible Church and its staff and volunteers from any and all liability, claim, demands, causes of action whatsoever arising out of or related to any loss, damage, or injury (including death) that may be sustained by my child while participating in this event. I agree to accept full responsibility, financially and otherwise for any damage that my child may do to the property of River Valley Bible Church. I agree to allow my child to be photographed and/or videotaped by the staff and volunteers of River Valley Bible Church, knowing that these may be used in future promotions of River Valley Bible Church's activities.

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