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Seal of the Diocese of Upper South Carolina

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Vacation Bible School
St. John's Episcopal Church
June 16 - 19, 2008
9:00 am - 12:00 pm

$10/child $20/family max

Parental Information

Parent(s) Name:

E-Mail Address:

Daytime Phone:

Evening Phone:

Cell Phone:

Address:
(street, city, state, zip)

Emergency Contact Person:

Phone Number:

Family Doctor:

Phone Number:

Child Information Add a Child Remove Checked Children

1) To enroll a child, enter information below.
2) To enroll additional children, click 'Add a Child' above.
3) To remove a child from your list, click in the box 'Remove Child' on the far right
and then click 'Remove Checked Children' above.
4) When you have read and agreed to the Medical Release below, click 'Continue'.

Name:		Remove Child
Date of Birth:	(mm/dd/yyyy)
Current Age:
Home Church:
Last School Grade Completed:
Allergies / Other Medical Conditions:

Medical & Liability Release - Valid from June 16 - 19, 2008
In the event of sickness or some medical emergency, I request that my child receive any medical attention or treatment deemed necessary, therefore I give permission to any hospital, doctor, and/or health care provider authority to transport, treat and/or admit for care my child. I understand that I am responsible for all expenses and charges for the treatment and care of my child. In the event that I am not present at the time of the emergency or cannot be contacted, my care has been entrusted to the staff and designated ministry leadership of St. John's Episcopal Church.

I Agree to the above Medical & Liability Release : Date: (mm/dd/yyyy)