Thank you for filling out this form in advance! Completing this form in advance will save everyone time the week of Vacation Bible School.
Please print this form and fill it out completely. Please mail this form to:
Wheat Field Fellowship Vacation Bible School
11000 E. Yale Ave. Ste. 225
Aurora, Colorado 80014
303-752-1125
We value your children and their safety. Please contact us with questions. Thank you for your cooperation!
Please PRINT legibly and fill out this form in full. Up to four (4) children per form, please.
Just a reminder that Lava Lava Island Vacation Bible School is open to all kids who will start Kindergarten through 5th Grade this fall!
Thank you!
MEDICAL RELEASE
Parent's Name(s)____________________________________________________________________________
Home Phone_____________________________Work Phone(s)________________________________________
Cell Phone(s)_______________________________________________________________________________
Address_____________________________________________________________________________________
Name_____________________________ Sex__________ Age__________ Birthday__________ Grade this Fall_______
Food or other Allergies, Special needs:__________________________________________________________________
Name_____________________________ Sex__________ Age__________ Birthday__________ Grade this Fall_______
Food or other Allergies, Special needs:__________________________________________________________________
Name_____________________________ Sex__________ Age__________ Birthday__________ Grade this Fall_______
Food or other Allergies, Special needs:__________________________________________________________________
Name_____________________________ Sex__________ Age__________ Birthday__________ Grade this Fall_______
Food or other Allergies, Special needs:__________________________________________________________________
***Is there anyone who is NOT authorized to pick up your child?__________________Name__________________________________________
Relationship to your child_________________________________________________________________________
Insurance Carrier______________________________________ Ins#____________________________________
Doctor's Name__________________________________________ Phone_____________________Office Location________________________________
Do any of your children suffer from asthma, diabetes, epilepsy, convulsions or seizures?_____________________________________________
Have they had any acute illness, injury, or surgery in the last three months?____________________________________________________
What medications do your children take?__________________________________________________________________________________
Other Medical Information _________________________________________________________________________________________________
In the event of an emergency where medical treatment is required I give permission to WFF personnel to obtain the services of a licensed physician.
Please attempt to notify the person named below (in addition to parents) concerning any emergency.
1st Person to Notify________________________Phone# __________________________ Cell Phone#__________________________
2nd Person to Notify________________________Phone# __________________________ Cell Phone#__________________________
LIABILITY RELEASE
In consideration of the acceptance this form, I do hereby for myself, my heirs, Executors and Administrators, waive release and forever discharge any and all claims with the rights for damages which I may have or which may hereafter accrue to me against Wheat Field Fellowship (WFF) and their respective Officers, Agents, Representatives, Successor, and/or assigns any damages and liabilities which may be sustained and suffered by me in connection with, participation in, or traveling to and from any event(s).
***Do you wish this registration form to also function as registration for the Sunday School Year 2003 to 2004?_______________
If so, please read the paragraph below for additional information before signing this form.
From time to time, our Children's Church or Sunday School classes may go outside or play an active game. Every precaution is taken to provide a safe and happy time for your children. By signing this form, I understand that no amount of instruction, precaution, and supervision will totally eliminate all risk of injury, and I release Wheat Field Fellowship and any authorized agents from any liability.
Parent/Guardian Signature___________________________________________________ Date_____________________________