Vacation Bible School Registration
3 year olds-6th Graders
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Child's Name *
Date of Birth *
(Month/Day/Year)
Address *
Home Phone Number *
Email where updates can be sent (announcements etc) *
Child's Grade Level as of 7-1-22 *
Child's Home Congregation (if different than Bethlehem)
Alternate Emergency Contact *
Name
Relationship to Child *
(ie parent, grandparent, friend, etc)
Alternate Emergency Contact Phone Number *
Are there any family situations we need to be aware of?
(ie custodial issues, other matters, etc)
Please let us know if you approve of the following for your child... *
(only check those that you approve of)
Required
Confidential Medical Report *
The information below is requested in case of any illness or accident.  Please check if your child suffers from any of the following:
Required
Allergies *
Is your child allergic to
Required
Please list any physical or special needs:
(ie dietary requirements, etc)
I authorize the leader(s) in charge of Bethlehem's Vacation Bible School, where it is impractical to communicate with me, to arrange for my child to receive such medical or surgical treatment as the leader(s) may deem necessary at any time during the activities of Bethlehem Lutheran Church.  I further authorize the use of ambulance and/or anesthetic by a qualified medical practitioner if in his/her judgment it is necessary.  I accept responsibility for payment of all expenses associated with such treatment.  I appreciate that every care will be taken by the leaders and recognize that those connected with the group cannot be held responsible for personal injury, loss, or theft of property affecting my child. *
My entering my below is my electronic signature that all the above information is accurate to the best of my knowledge.
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