VBS Medical Information & Release Form Medical Information and Release Seaside United Methodist Church 1300 Seaside Rd., SW Sunset Beach, NC 28468 For Vacation Bible School, June 23-27, 2014 Child's Name First Last Enter the name of child.Level in School*Please Select OneCompleted Pre-KindergartenCompleted KindergartenCompleted 1st GradeCompleted 2nd GradeCompleted 3rd GradeCompleted 4th GradeAge*Please Select4 Years Old5 Years Old6 Years Old7 Years Old8 Years Old9 Years Old10 Years Old11 Years OldName of SchoolDate of Birth MM DD YYYY Name of Parent/Guardian* First Last Add a second Parent/Guardian?*YesNoName of additional Parent/Guardian First Last Person Completing this form:Parent/Guardian aboveSecond Parent/Guardian listedOtherName of Person Completing Form* First Last Relationship to Child*Address where child lives* 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 Home PhoneParent/Guardian Work PhoneParent/Guardian Cell PhoneSecond Parent/Guardian Cell PhoneAlternate Contact in Case of Emergency* Alternate Contact Phone #*Relationship to Child*Family Doctor*Phone Number*Family DentistPhone NumberDoes the child have health insurance?*YesNoHealth Insurance Company*Policy Number*Insurance Company Phone Number*List all known allergies.*If none, please enter none.Medical History-brief description of child's medical history and any know condition*List all medications and frequency of use.*If none, please enter none.Dietary or physical restrictions.*If none, please enter none.In the event I am unable to be reached at the numbers above, I hereby authorize emergency medical treatment, surgery, or dental care to be given to my son/daughter, as considered advisable or necessary in the judgment of an emergency medical professional or attending physician. I shall be liable and agree to pay all costs and expenses incurred in connection with any medical services need for my youth. Consent*I agree to the above consent statementDate* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Share this:PrintEmailFacebook