Sky Vacation Bible School
At Saint Bernadette Catholic Church!
June 18th-22nd
Registration and Liability Waiver

*Father's name:
*Mother's name:
*Zip Code:
Phone number
*(daytime):                 (evening):
*Email address:
Emergency Contact:
*Home phone:                    Cell:

Registration is available for children who are finishing Kindergarten through finishing 5th grade. A fee of $50 per child is due by May 11th. Late registrations will not be considered.

*Child #1:
    Age:     Grade finishing this year:
Child #2:
    Age:     Grade finishing this year:
Child #3:
    Age:     Grade finishing this year:
Child #4:
    Age:     Grade finishing this year:
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.)

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name & relationship: Phone:
Family doctor: Phone:
Family Health Plan Carrier: Policy #:

Please check the box if these statements apply to you and your child/children.

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life threatening and emergency treatment is required.

I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

Specific Medical Information: The parish will take reasonable care to see that the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.):

Immunizations: Date of last tetanus/diphtheria immunization:

Does child have a medically prescribed diet?

Any physical limitations?

Is child subject to chronic homesickness, emotional reactions to new situations, fainting?

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition:

You should be aware of these special medical conditions of my child:

* I accept the terms and conditions of St. Bernadette Church Vacation Bible School.