VBS Medical Release Form

Name *

First

Last

Birthdate *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Name *

First

Last

Parent/Guardian Phone Number

Parent/Guardian Email *

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Participants and their guardians agree to the following:

I give permission for my child to attend and to participate in the activities at Kenilworth Gospel Chapel. In case of medical emergency, every effort will be made to contact me. However if I cannot be reached I give my permission to the staff at Kenilworth Gospel Chapel to secure the services of emergency personnel/licensed physicians to provide the necessary care, including anesthesia, surgery or hospitalization (if necessary) for my child's well being.

Medical Insurance Carrier: *

Policy #: *

Requested Hospital:

Allergies/Medical Issues:

Participants and their guardians agree to to the following:

I UNDERSTAND THAT KENILWORTH GOSPEL CHAPEL, THE VACATION BIBLE SCHOOL PROGRAM AND ITS STAFF WILL NOT BE LIABLE FOR ANY MEDICAL TREATMENT SUPPLIED OR RESPONSIBLE FOR ANY MONETARY INCURRENCE FOR SAID MEDICAL TREATMENT.

Date *

Parent/Guardian Signature *

VBS Medical Release Form

Kenilworth Gospel Chapel – 557 Newark Avenue – Kenilworth NJ 07033-1643 – (908) 272-6131