Westminster Church Youth Programs

VBS 2008

Child Registration, Emergency Medical Authorization and Liability Waiver

Contact Information:

Last Name:

Mother:

Father:

Work Phone:

Work Phone2:

Home Phone:

Cell Phone:

Home Address:

EMail:

Home Church:

Additional emergency contact name and phone:

Name:

Phone:


Food/Bee Allergy and other applicable information:	Carpooling info: (People other than Mom and Dad authorized to transport children)

Childrens Medical Information:

Physician’s Name:

Physician’s Phone:

Insurance Plan Name:

Insurance Plan Number: