I, (parent) ______________________________agree that,
(child’s name) _________________________
may participate in the Our Savior Lutheran Church Vacation Bible School program. In consideration of participation in this event, I agree, on behalf of the above named child, his/her heirs and representatives to fully and forever release, discharge, indemnify and hold harmless Our Savior Lutheran Church, its agents, servants and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of participation in this event. I HEREBY AUTHORIZE IN ADVANCE ANY NECESSARY MEDICAL TREATMENT REQUIRED BY THE ABOVE NAMED CHILD WHILE IN ATTENDANCE OF VACATION BIBLE SCHOOL. I ALSO ACKNOWLEDGE THAT I HAVE/WILL NOTIFY THE VBS PERSONNEL OF ANY SPECIAL MEDICAL NEEDS OR INFORMATION REQUIRED BY THE ABOVE NAMED CHILD. Also, I understand that all rules and regulation for Vacation Bible School will be enforced and violations by my child may result with a request to come and pick up my child.
Name of Physician
______________________________________
Phone Number ____________________
__________________________________________________ ________________________________
Instructions:
Please complete and sign a copy of this form for EACH
child that you are registering. (ie. 3 children means you send 3 signed copies
of this form)
Mail or deliver all signed copies to:
Our Savior Lutheran Church
Attn: VBS
239 Graham Road
South Windsor, CT 06074
If you have any questions, visit http://www.oursaviorct.org/vbshome.htm,
or call the VBS director.
Beverly Gayman