Child's Name * First Name Last Name Child's Age * Child's Birthdate * MM DD YYYY Parents Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Allergies or Special Needs Doctor's Name & Contact Who is able to pick up your child? First Name Last Name Relationship I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in all the scheduled VBS activities of Texas City First Assembly of God Church, and any other supervised activities customarily associated with its children's group. If I wish to revoke this consent for any reason, I will promptly notify the children's ministry leader in writing. I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my youth is injured or becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my child, if required by law or a health care provider: Pastor Alexandria Zahirniak, or another adult chaperone designated by the pastor. I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that these persons will not be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the children's ministry director in writing of any health changes that would restrict my child’s participation in any normal VBS activities. I also understand that the children's leader and designated adult chaperones reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child. * Yes No Parent's Signature * Thank you!
