REGISTRATION Please bring a sack lunch each day. MEDICAL ...
REGISTRATION
MEDICAL INFORMATION & RELEASE
Travis Park UMC Vacation Bible School 9:00 am-3:00 pm July 10-14, 2017
Authorization for Treatment of a Minor Travis Park United Methodist Church (TPUMC)
Please bring a sack lunch each day. Child’s Name
M F (Circle one)
Birth Date
Child’s Name Date of Birth
/
/
Age
Physician’s Name__________________________ Office Phone
Grade Completed
My child is subject to the following health problems:
Home Phone Allergies:
Street Address
Medications taken on a regular basis:
City, State, Zip
_________________________________________________________________
Mother’s Name Day Phone
I give permission for authorized VBS officials to administer PRESCRIPTION medication.
Cell Phone
□YES
Instructions:
□NO
Father’s Name Day Phone
Cell Phone
I give permission for authorized VBS officials to administer NON-PRESCRIPTION
E-Mail ___________________________________________________________
medication (such as Tylenol) as instructed..
Who will pick up your child from VBS? ________________________________________
Other special needs/concerns:
Additionally, my child may be released to any of the following (if applicable):
Medical Insurance Company
Name
Ph
Relationship
Policy #
Name
Ph
Relationship
T-Shirt size (circle one): CHILD: XS (2-4) S (6-8)
M (10-12) L (14-16)
ADULT: S M
L XL
I would like to be a lunch helper . ....................... 11:40 - 12:15 M T W Th F (circle your preferred days)
I give permission for TPUMC’s assumption of parental privilege in all EMERGENCY medical, dental and general health situations. I understand that TPUMC accepts no responsibility for medical liability. I will be billed for any medical expenses incurred. In conjunction with the Medical Practice Act, this authorization is given pursuant to the provisions of Section 35.01 of the Texas Family Code. Signature of Parent/Guardian
$25.00
Lunch (bring own sack lunch) . . 12:00 - 12:30 pm
---
Total
Please complete other side.
$50.00
scholarships available
□After Care . . . . . . . . . . . . . . . . ..... . .3:00 - 6:00 pm
□
---
□NO
Phone # 1-800-_________________________
Check the box which corresponds with the section(s) you want your child to attend:
□ Early Drop Off .......................................7:45-8:45am □ VBS .................................................9:00am-3::00 pm
□YES
Date
PHOTO RELEASE
□
Please check one: Permission granted Permission NOT granted for photograph(s) of my child to be used on the church Facebook page, website (www.travispark.org), and/or in printed church brochures, flyers or newsletters. Signature of Parent/Guardian
Date
Travis Park United Methodist Church 230 E. Travis Street • SA, TX 78205 (210) 226-8341 • fax (210) 226-8344 • www.travispark.org
unconditional love and justice in action
MEDICAL INFORMATION & RELEASE
Travis Park UMC Vacation Bible School 9:00 am-3:00 pm July 10-14, 2017
Authorization for Treatment of a Minor Travis Park United Methodist Church (TPUMC)
Please bring a sack lunch each day. Child’s Name
M F (Circle one)
Birth Date
Child’s Name Date of Birth
/
/
Age
Physician’s Name__________________________ Office Phone
Grade Completed
My child is subject to the following health problems:
Home Phone Allergies:
Street Address
Medications taken on a regular basis:
City, State, Zip
_________________________________________________________________
Mother’s Name Day Phone
I give permission for authorized VBS officials to administer PRESCRIPTION medication.
Cell Phone
□YES
Instructions:
□NO
Father’s Name Day Phone
Cell Phone
I give permission for authorized VBS officials to administer NON-PRESCRIPTION
E-Mail ___________________________________________________________
medication (such as Tylenol) as instructed..
Who will pick up your child from VBS? ________________________________________
Other special needs/concerns:
Additionally, my child may be released to any of the following (if applicable):
Medical Insurance Company
Name
Ph
Relationship
Policy #
Name
Ph
Relationship
T-Shirt size (circle one): CHILD: XS (2-4) S (6-8)
M (10-12) L (14-16)
ADULT: S M
L XL
I would like to be a lunch helper . ....................... 11:40 - 12:15 M T W Th F (circle your preferred days)
I give permission for TPUMC’s assumption of parental privilege in all EMERGENCY medical, dental and general health situations. I understand that TPUMC accepts no responsibility for medical liability. I will be billed for any medical expenses incurred. In conjunction with the Medical Practice Act, this authorization is given pursuant to the provisions of Section 35.01 of the Texas Family Code. Signature of Parent/Guardian
$25.00
Lunch (bring own sack lunch) . . 12:00 - 12:30 pm
---
Total
Please complete other side.
$50.00
scholarships available
□After Care . . . . . . . . . . . . . . . . ..... . .3:00 - 6:00 pm
□
---
□NO
Phone # 1-800-_________________________
Check the box which corresponds with the section(s) you want your child to attend:
□ Early Drop Off .......................................7:45-8:45am □ VBS .................................................9:00am-3::00 pm
□YES
Date
PHOTO RELEASE
□
Please check one: Permission granted Permission NOT granted for photograph(s) of my child to be used on the church Facebook page, website (www.travispark.org), and/or in printed church brochures, flyers or newsletters. Signature of Parent/Guardian
Date
Travis Park United Methodist Church 230 E. Travis Street • SA, TX 78205 (210) 226-8341 • fax (210) 226-8344 • www.travispark.org
unconditional love and justice in action
