VBS RxR New Student Form Number of Children To Register*1234Child 1Child's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2022-23)*3.Y.O to Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th +Date of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsChild 2Child's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2022-23)*3.Y.O to Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th +Date of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsChild 3Child's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2022-23)*3.Y.O to Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th +Date of last tetanus shot MM DD YYYY MedicationsAllergiesAdditional Notes or CommentsChild 4Child's Name* First Last Birthdate* MM DD YYYY Grade (School yr: 2022-23)*3.Y.O to Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th +Date of last tetanus shot MM DD YYYY AllergiesMedicationsAdditional Notes or CommentsParent / Guardian InformationRelation*FatherMotherMale GuardianFemale GuardianIf Guardian, relationship to child (or children)*Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Phone or Cell Phone*Work PhoneAdd Another Guardian/Parent YES Parent / Guardian InformationRelation*FatherMotherMale GuardianFemale GuardianIf Guardian, relationship to child (or children)*Name* First Last Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Phone or Cell Phone*Work PhoneChild (or Children) lives with...RelationshipChild may be taken home by...Names of individuals besides parent / guardianWhat address should information be mailed to?Emergency ContactsName* First Last Phone*Relationship*Name* First Last Phone*Relationship*Medical Release / PermissionAgreement*I give permission for each child listed above to participate in the Discovery Hills Church VBS. I agree *In the event I cannot be reached in an emergency, I give the adult sponsor of VBS or Discovery Hills Church Staff permission to consent to any x-ray, examination, anesthetic, or medical or surgical services needed on the advice of a physician or surgeon licensed to practice in the state of treatment when the need for such treatment is immediate. I agree Please type your full name as a consent*Today's Date* MM DD YYYY RelationshipMedical InformationPhysician's Name First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy #Additional notes, restrictions, etc.
