Community Vacation Bible School Arlington Forest United Methodist Church, Arlington Church of the Brethren and Bethel United Church of Christ When: August 2-7, 2015 6 pm to 8 pm Where: Arlington Forest United Methodist Church 4701 Arlington Blvd, Arlington, VA 22203 Cost: $25/person or $50/ family; children under 2 free paid at registration. Checks payable to Arlington Forest United Methodist Church Final deadline for registration July 17, 2015 Participants Name(s) with age and grade for children Home Phone Cell Phone Families are encouraged to attend together. If a child will be dropped off for VBS, please provide two local emergency contacts (persons other than parents) Contact Name Home Phone Address Cell Phone Contact Name Home Phone Address Cell Phone Children’s Medical Information Pediatrician Pediatrician Phone Number Special Medical Problems? Allergies? Please note we will not administer any medication. Please sign and complete page 2. Page 1 of 2 MEDICATION POLICY COMMUNITY VBS WILL NOTIFY PARENTS WHEN A CHILD BECOMES ILL. IF PARENTS ARE NOT PRESENT, PARENTS AGREE TO HAVE THE CHILD PICKED UP IMMEDIATELY. No medication will be given to a child during Community Vacation Bible School by any of our volunteers, with the following exceptions:  If the child has a known, life threatening medical condition that would require 911 attention, the family should notify Pastor Kristen Curlee. These types of conditions may include, but are not limited to asthma attacks, serious allergies or seizures.  In the case of life threatening medical conditions, the parents should submit an emergency health plan for the child (see Pastor Curlee for details).  Medication must be submitted to the volunteers with the label intact and expiration date visible (examples would include an inhaler or epipen).  Medication, again, is only dispensed when there is a known life threatening condition and the above requirements are in place. EMERGENCY TREATMENT AUTHORIZATION I, ___________________________ hereby authorize Dr. ______________________ and/or any other member of the nearest hospital medical staff to render medical treatment which in his/her/their judgment may be deemed necessary in the care of ________________________ on August 2-August 7, 2015. Medical Insurance Co. ___________________________ Policy Number _________________________________ Signature ___________________________________________________ Date ______________ PERMISSION TO PICK UP (to be complete if a child will be dropped off) For the safety of your children, we will only release your child to a parent or someone on this list. Please Child(ren)’s Name _____________________________________________________ Other friends or relatives who have permission to pick up your child: Name Phone . (for all parents and guardians) Is there anyone to whom we should not, under any circumstances, release your child? Name Description Parent/Guardian Signature Date . Page 2 of 2