Child's Name *

First Name

Last Name

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Phone

(###)

###

####

Phone

(###)

###

####

In the event of emergency, I authorize the First United Methodists’ VBS Staff consent to appropriate medical treatment for my child

yes

no

Physician's Phone

(###)

###

####

Media Release *

First United Methodist Church may use photographs and video of my child’s participation in VBS activities. I understand that photo and video images will NOT be labeled with children’s names.

yes

no