VBS Jasper Canyon Registration
Event Timing: July 25-29, 2022 from 5:30-7:30 PM
Event Address: Wichita South SDA Church:
820 W 27th St S. Wichita, KS 67217
Contact us at: whitniann@gmail.com (director's email address)
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Name *
Date of Birth *
YYYY
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MM
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DD
Age *
Parent or Guardian Name *
Email Address *
Street Address *
Phone Number *
Home Church *
Emergency Contact *
Doctor *
Preferred Hospital *
Special Needs or other Concerns *
What days will your child attend? *
Privalomas
Allergies *
Consent to Photograph: I hereby give my consent for my child to be photographed during VBS summer of 2021 with various activities and crafts. I consent to these photographs to be used for posters as described by various honors, for display at church events or for advertisement of our program (checking "yes" is my digital signature of agreement). *
Privalomas
Authorization to Treat a Minor: I, the undersigned parent or legal guardian of the above registrant, in case of an emergency, I hereby give permission to the physician selected by the VBS directors to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child.As parent or legal guardian of the applicant, I am in favor of him/her attending club functions and accept the conditions named. The health history stated is correct so far as I know, and the person herein described has permission to engage in all prescribed club activities except as noted. In addition, I have read and understand the Emergency Authorization statement and give my full consent to the terms found therein. Permission for photocopying of this health record is granted (checking "yes" is my digital signature of agreement). *
Privalomas
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