Vacation Bible School
Child 1
*
Full Name
*
Age
*
Birthday
*
Grade Completed
Pre-K
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
*
Sex
Male
Female
*
Address 1
Address 2
*
City
*
State
*
Zip
*
Home Phone
Cell Phone
*
Email
*
Mother's Name
*
Home Phone
Work Phone
Father's Name:
Home Phone:
Work Phone:
*
Emergency Contact
*
Home Phone
Work Phone
*
Medicl Insurance Company
*
Policy Number
Medical History
1. Does your child have allergies to
Pollens
Medications
Food
Insect Bite
Specify Allergies
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following
Asthma
Epilepsy/Seizure Disorder
Heart Trouble
Diabetes
Frequently Upset Stomach
Physical Handicap
Specify
3. Please list and explain any major illnesses the child experienced during the last year
4. Should this child’s activities be restricted for any reason? Please explain
*
Indicates Response Required
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