Vacation Bible School Registration – Nottingham Baptist Church

Name of Parent/Guardian *

First

Last

Relationship to Minor(s) *

Address *

Phone Number *

Email *

Total Number of Children Being Registered *

Names and Ages of Minors *

Please include minor’s first and last name. Example: John Smith 5, Sally Smith 11

Family Physician and Physician Phone Number *

Specific Medical Conditions

Include any allergies such as food, medical, etc.

Additional Contact Person *

First

Last

Additional Contact Person Phone Number *

As a parent/guardian, I do herewith authorize treatment under the direction of any licensed physician of the above minor(s) in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after reasonable effort has been made to contact me. I will assume responsibility of any costs connected with such treatment, and hereby release Nottingham Baptist Church from any liability. *

Please read the above statement, and then type your name and today’s date as confirmation of full agreement with said statement.