First United Methodist Church of Orange
Vacation Bible School Registration Form

 Youth T-Shirt Size
Child's Name Child's Name is required.
Date of Birth Birthdate is required.Please enter date mm/dd/yyyy Age Age is required.Enter Age as a numberMust be at least 4 years old.Must be in grade 6 or lower. Last grade completed
Allergies / Medical Information /
Other
 
Parent/Guardian Name A parent or guardian name is required.
E-mail Invalid email format.
Address Address is required.
City City is required. State Zip 5 digit zip code is required.Invalid format.

Phone Numbers
HomeCellWork
Home phone is required.Enter phone as (123) 456-7890 Enter phone as (123) 456-7890
 
 NamePhone
Emergency Contact 1 At least one emergency contact is required. At least 1 emergency contact is required.Enter phone as (123) 456-7890
Emergency Contact 2
 
Medical Release I (we) the above named parent(s)/guardian(s) of the above named child, a minor, do hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis rendered under the supervision of any member of the medical staff and emergency staff licensed under the provisions of the Medicine Practice Act or a dentist licensed under the provision of the Dental Practice Act and on the Staff of any acute general hospital holding a current license to operate a hospital from the State of California, Dept. of Public Health. It is understood that this authorization is given in advance of any diagnosis, treatment or hospital care being required but it is given to provide authority and power to render care when the aforementioned physician in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the above named parent(s)/guardian(s) prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the above named parent(s)/guardian(s) cannot be reached. The authorization is given pursuant to the provisions of Section 25.8 of the California Civil Code.
  To enroll, you must check the box to electronically sign the Medical Release By checking this box, you agree to the above Medical Release and authorization