| Child's First Name: |
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| Child's Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| Birthdate: |
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| Grade in Fall 2008: |
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| Gender: |
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| Mother's Name: |
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| Mother's Phone Number: |
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| Father's Phone Number: |
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| Father's Name: |
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| Emergency Contact Name: |
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| Emergency Contact Number: |
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| Allergies? If Yes, please list: |
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| Other Medical Conditions?: |
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| Physician's Phone Number: |
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| Physician's Name: |
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| List ALL adults authorized to pick up your child: |
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| Names of up to 4 friends your child might like to be with: |
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| How did you hear about our VBS?: |
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| In case of emergency, I authorize The Fellowship of San Antonio to seek medical attention for my child. The Fellowship of San Antonio does not assume any financial responsibility, but will provide or arrange for emergency care. By submitting this form, you are giving the appropriate VBS personnel authority to call EMS, to transport, or to obtain medical care if you or the alternate adults cannot be reached.: |
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Parents/Guardian - Click the box to acknowledge that you have read the above disclaimer. |
| * Enter Your Name as Your Signature: |
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