Durham Evangelical Church - resources
 

vbs signup form


Fields marked with * are mandatory

*Child's First Name:
Middle Initial:
*Child's Last Name:
*Age:
*Grade entering Fall '10:
*Mailing Address:
*City:
*State:
*Zip Code:
*Mother's name:
*Father's name:
*Home Phone:
*Date of Birth: / /
*Gender:
Invited to VBS by:
Church that child/family attends:
Additional phone numbers for parents:
If parent can't be reached, call:
At phone:
Other adults who have permission to take this child home:
Special medical/developmental instructions:
Food allergies:
Other allergies (not food):
I, the parent named above on this form, am the parent or legal guardian having custody of the minor child listed above on this form. As such parent or legal guardian, I hereby authorize and appoint Durham Evangelical Church (DEC), its staff or volumteers in whose care the minor child has been entrusted as my agent to act for me with respect to my minor child, from the 2nd day of August, 2010 to the 6th day of August, 2010 and in my name in any way I could act in person to make any and all decisions for me with respect to my minor child, concerning my minor child's personal care, medical treatment, hospitalization and health care and to require, withhold or withdraw any type of medical treatment or procedure, including X-ray examination, anesthetic, medical or surgical diagnosis or treatment which may be rendered to my minor child under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state in which treatment was sought.

* Please check here to indicate that you have read and understood the above terms.