East Granby Congregational Church

 

Please complete and return this form, with your payment of $10.00 per child (max. $25.00 per family),  to EGCC at:

P.O. Box 390, East Granby, CT 06026 by August 1, 2019, if possible!

 

Student’s Name ____________________________________________________________________________________________________________________________

 

Parent/Guardian Name __________________________________________________________________________________________________________________

 

Address_____________________________________________________________________________________________________________________________________

 

E-mail Address _____________________________________________________________________________________________________________________________

 

Phone Numbers    Home __________________   Cell ____________________________     Work __________________

 

Age Information

                Date of birth ________________________        Age ________________________        Last school grade completed________________

               

Home Church ____________________________________________________________________________________________________________________________

 

Photos I give East Granby Congregational Church permission to use photos of  my child, participating in VBS , in Church publications   _____Yes _____No  and  on EGCC website and social media _____Yes _____No  (no names will be used)

 

Dismissal Information

Name(s) of person(s) who may pick up this child from VBS

__________________________________________________________________­­____________________________________________________________________

 

Allergies/Medical Information/Other: ______________________________________________________________________________________________

 

_____________________________________________________________________________________________________________________________________________

Emergency Contacts:

                Name _________________________________________________ Phone ______________________________

 

                Name _________________________________________________ Phone ______________________________

 

I understand that in the event, medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activities shown on this form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.

I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by the East Granby Congregational Church, through its accident guidelines will be used as a backup for what my family's insurance does not cover. I understand all reasonable safety precautions will be taken at all times by the East Granby Congregational Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold East Granby Congregational Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

 

Parent/Guardian Signature: __________________________________ Date: _____________

        __________________________________ Date: _____________