Who: Children from Ages 8-13

When: June 14th-June 16th, 6:00pm-8:00pm

Where: Washington Playground (On Woodley Rd, between N. Wright Ave. & N. Garland Ave.)

Child's Name

If you have more than one child, please fill out multiple forms

First Name

Last Name

Age

Parent's Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Emergency Phone

(###)

###

####

Allergies

Insurance Policy

Medical Treatment Authorization We (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 under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. We (I) 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 or youth pursuant to this authorization. Yes, I/We consent to the above Medical Treatment Authorization No, I/We do NOT agree TO CONFIRM CONSENT TO THE ABOVE MEDICAL TREATMENT PERMISSION, TYPE INITIALS HERE:

Medical Consent

If you answer "No", you will be required to signup in person at CBC the week of VBS.

Yes

Insurance?

Yes

Insurance Provider

How did you hear about Backyard Bible Club?

Church Home?

Yes

Church Home Location

If you have a church home, please let us know where you attend.

* Required field

Backyard Bible Club

SUNDAYS

WEDNESDAYS

LOCATION