VBS Participant (Grades K-5) Registration

Child #1 Full Name:

Child #1 Birthdate:

Child #1 Gender:

Child #1 school grade for upcoming school year:

Any allergies, medical conditions, or special needs?

Physician's Name and Phone #:

Child #2 Full Name:

Child #2 Birthdate:

Child #2 Gender:

Child #2 school grade for upcoming school year:

Any allergies, medical conditions, or special needs?

Physician's Name and Phone #:

Child #3 Full Name:

Child #3 Birthdate:

Child #3 Gender:

Child #3 school grade for upcoming school year:

Any allergies, medical conditions, or special needs?

Physician's Name and Phone #:

Child #4 Full Name:

Child #4 Birthdate:

Child #4 Gender:

Child #4 school grade for upcoming school year:

Any allergies, medical conditions, or special needs?

Physician's Name and Phone #:

Family Email:

Family Phone:

Street Address, City, State, Zip:

Registered member of SAtG?

Yes

If not a member, what parish are you a member of?

Emergency Contact #1 First and Last Name:

Relationship:

Phone Number:

Emergency Contact #2 First and Last Name:

Relationship:

Phone Number:

My child/children has/have permission to attend Vacation Bible School at St. Albert the Great Parish. I will drop off my child at St Albert the Great each day, and will pick them back up. I agree on behalf of myself and my child’s other parent, my child or our heirs, successors and assigns, to hold harmless St. Albert the Great Parish, The Dioceses of Knoxville, its officers, directors and agents, the Archdiocese of Louisville, chaperones or representatives associated with the event, arising from or in conjunction with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the Diocese of Knoxville, Archdiocese of Louisville, chaperones or representatives associated with the event for reasonable attorney fee and expenses arising in connection therewith. In the event of an emergency, I hearby give permission to treat and transport my child to the hospital for emergency medical treatment. I wished to be advised prior to any further treatment by hospital or doctor. Type name and date here for electronic signature:

VBS Participant (Grades K-5) Registration

VBS Participant (Grades K-5) Registration

7200 Brickey Lane

Knoxville, TN 37918

(865) 689-7011