VBS Application 2013

To pay online complete and submit the registration form and complete the payment of $10 (per child) at the end through paypal. Or click here for a printable version of the VBS registration form that can be dropped off at Clovis Christian Church office with the $10 (per child) payment.

Fields marked with a "*" are required.

Child's Last Name*:	Child's First Name*:

Age*	Grade (as of May 2013)*	T-Shirt Size:*

Father's Name:*	Mother's Name:*
Child Lives With:*	Child's Home Address:*
Home Phone:	Cell Phone:*

Family Email Address:*

Home Church:
None

Release Child To: Father Mother Mother/Father

Other:

Emergency Contact: (other then listed above)

Name:* Phone:*

Clovis Christian Medical Release

This Child has a known helath condition Yes No
If so, please explain:

Name of Medical Insurance:*		Insurance ID #:*
Preferred Family Physican:		Phone #
Preferred Family Dentist:		Phone #
Preferred Hospital:

Consent for Medical Treatment (minor): As the parent or legal guardian of the above named children, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medical Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. This authorization will stand until revoked by me in writing.

Electronic signature indicats that the above information provided is true and correct.

Electronic Singature (type full name):*	Date:*

Photo Release

I give my permission for photographs/video of my children to be used by Clovis Christian Church.

Electronic Signature (type full name):*

Date:*