Child's Name
Child's Information
Date Of Birth *
Date Of Birth
Parent's Name
Parent's Information
Cell Phone
Cell Phone
Work Phone *
Work Phone
Home Phone
Home Phone
Address *
Address
Additional Persons Authorized To Pick Up Child From V.B.S. Daily
Person Picking Up Must Be 18 Years Old Or Older (Any other person will be turned away if not listed here).
Authorized Person 1
Name
Name
Cell Phone
Cell Phone
Work Phone
Work Phone
Authorized Person 2
Name
Name
Cell Phone
Cell Phone
Work Phone
Work Phone
Consent For Medical Care And Photo Release
I the parents of the child being registered, do hereby authorize the person presenting this form to call a physician and to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care which is deemed to be advisable for my child. It is understood that a conscientious effort must be made to notify me before such action is taken. It is further understood that I release the person presenting this form of all liabilities connected with the transportation, diagnosis, treatment and hospital care and expenses necessary for the treatment of my child. This authorization is given pursuant to the provision of Section 25.8 of the Civil Code of the State of California. In the event of a minor illness or injury (such as a headache, scrapes, sprains, abrasions, and/or small cuts) I do authorize the Director, Medical Staff, R.N. or E.M.T. to give my child common remedies such as Tylenol, etc. in dosages appropriate for his/her age, and to clean and bandage or wrap wounds as necessary. Photo Release: I (We) understand that by participating in this Children’s Ministry program, I give my permission for the publication of photographs, videos, and recordings taken during participation in any Children’s Ministry activity, to be used in promotional materials. I understand that I will not be paid any royalty or other compensation; and I give up any right I may have to payment if photos, videos, or recordings are published. I agree that any such media shall become the sole property of Calvary Chapel of Downey.
Please Check The Box Below That You Agree *
Today's Date *
Today's Date
Medical Information
Phone *
Phone
Date Of Birth *
Date Of Birth