Christ the Servant Parish Vacation Bible School Registration 2015 Date: June 22-26, 2015 (Time: 9:00 AM-12:00 PM) Preschool Age 3 – Grade 5 PLEASE PRINT the following information: Parent name_____________________________________________________ Phone # _________________________ Mailing address ____________________________________________________________________________________ Email address ______________________________________________________________________________________ We are registered members of Christ the Servant Parish. ____ Yes ____ NO ______ We would like to register as a member of the parish. ______ We would like to receive the parish e-newsletter. First Name Middle Initial Last Name st 1 child_______________________________________________________________________ Age _______ Grade in the fall __________ 2nd Child: ______________________________________________________________________ Age ________ Grade in the fall ___________ Third Child:____________________________________________________________________ Age ________ Grade in the fall ___________ Fourth Child: __________________________________________________________________ Age ________ Grade in the fall ___________ ________ I can help by: ______ volunteering my time Available: (Please circle) SUN M _____decorating/preparing materials T W TH F Bible School Registration fee Each student……………………………………………………………………………. $12.00 Maximum per family ………………………………………………………………… $30.00 Please send registration to: Our Lady of Peace School Office or Christ the Servant Parish, 833 39th St. NW, Canton, OH 44709. Make checks payable to: Christ the Servant Parish. 14, 2015. Call (330 492-0757) for more information. Payment is due on or before the first session. Registration is due Sunday, June Christ the Servant Parish Confirmation Emergency Medical Form 2015/16 Please PRINT the following information Student’s name ____________________________________________________________________________________ Parent(s)/Guardians name(s) _________________________________________________________________________ Phone number where parents can be reached during Bible School): Name ____________________________________________ phone number _______________________________________ Name ____________________________________________ phone number _______________________________________ Please indicate the name(s) of the person(s) with whom the student is permitted to leave: Name ________________________________________ Relationship to the student _______________________ Name _______________________________________ Relationship to the student _______________________ Special Medical/Educational Needs (Please CIRCLE any that apply to this student) ADD/ADHD Asthma Autism Allergies Behavioral Hearing/Vision Physical Need Further explanation of above needs _________________________________________________________________________ ______________________________________________________________________________________________________ Purpose: To enable parents/guardians to authorize the provision of emergency medical treatment for children who become ill or injured while under Church authority, when parents/guardians cannot be reached and to ensure the child’s safety and well being. In case of an emergency, the following procedure will be followed: 1. Parent(s) will be notified. 2. Emergency medical treatment will be administered according to consent. 3. If necessary, 911 will be notified, according to consent. 4. If I cannot be reached, please contact: ______________________________________________________________ Relationship to student _____________________________________ Phone # _________________________________ Part I: To grant Consent _____ I GIVE FULL PERMISSION for medical attention to be given or to transport my child to a hospital if either I or the above named representative cannot be contacted. I hereby authorize medical personnel to release necessary information about my child’s care to Bible School staff. Preferred Hospital ____________________________________________________________________________________ Physician ___________________________________________ Phone # __________________________________________ Medical information/concerns: Please note any allergies, medications, surgeries, or medical concerns that would be helpful in case of an accident or emergency. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ________________________________________________ Signature of Parent/Legal Guardian ________________________________________ date Part II: Refusal to Consent _____ I DO NOT GIVE PERMISSION for any medical attention to be given to my child. In the event of illness or injury requiring emergency treatment, I wish Bible School Staff to take the following action: ______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ ____________________________________________ Signature of Parent/ Legal Guardian ___________________________________ ________________ Date