Author: CP Church

CHILD NAME_____________________________________________________________________________
CHILD’S BIRTHDAY__________ GRADE ENTERING IN THE FALL________
PARENTS NAME(S)__________________________________ _____________________________________
ADDRESS:________________________________________________________________________________
CITY:__________________________________STATE:______________________ZIP:___________________
E-MAIL__________________________________________________________________________________
PARENT’S PHONE:_________________________________________________________
NON PARENT EMERGENCY CONTACT
NAME: __________________________________________ PHONE:___________________
RELATIONSHIP: ____________________________________
ALLERGIES/MEDICATIONS/OTHER THINGS WE SHOULD KNOW ABOUT?________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________
PARTICIPATION AND MEDICAL RELEASE: BY REGISTERING MY CHILD, I GIVE PERMISSION FOR MY CHILD TO
PARTICIPATE IN VACATION BIBLE SCHOOL AND FOR ANY PICTURES TAKEN WHILE ATTENDING TO BE USED ON
COLLEGE PLACE PRESBYTERIAN CHURCH’S WEBSITE, PUBLICATIONS, AND AT CHURCH FUNCTIONS. IN THE EVENT
THAT MEDICAL TREATMENT IS REQUIRED, I GIVE PERMISSION FOR CPPC TO ADMINISTER MEDICAL CARE, AND
UNDERSTAND THAT IF FURTHER TREATMENT IS REQUIRED, YOU (CPPC) WILL ATTEMPT TO REACH ME AT THE PLACE
LISTED ABOVE AND ALTERNATELY THE “EMERGENCY CONTACT PERSON”. IF NEITHER OF US CAN BE REACHED I
GIVE MY PERMISSION TO THE STAFF OR VOLUNTEER TO MAKE REASONABLE EFFORTS TO SECURE SERVICES AT
EITHER A HOSPITAL OR WITH A LICENSED PHYSICIAN.
Parent/Guardian Signature
Signed By

PD	ALLERGY	IN DATABASE	MEMBER

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