Anchor Baptist Church
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Vacation Bible School Registration 2009

Email address
Date of birth / /
City / State / ZIP
 
Father's Info
Name
Home Phone
Work Phone
Cell/Pager
 
Mother's Info
Name
Home Phone
Work Phone
Cell/Pager
 
Name of church child attends
Emergency Contact
Emergency Phone
 
Authorization for Emergency Medical Attention
In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the person in charge to take my child to:
Name of Licensed Physician
Physician Phone
Street / PO Box
City / State / ZIP
OR TO
Name of Hospital or Clinic
Hospital Phone
Street / PO Box
City / State / ZIP
OR
The nearest hospital
I give my consent for necessary emergency treatment
 

By digitally signing my name below I certify that I am the child's parent or legal guardian and that I give my permission for my child to take part in all Vacation Bible School activities and absolve the church from liability to me or my child because of any injury to my child at Vacation Bible School or during any Vacation Bible School activity. In the event that I cannot be reached to make arrangements for emergency medical attention, the person designated by Anchor Baptist Church may authorize necessary emergency medical treatment and transportation.

 
(Type your name)
 



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