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East Lake United Methodist Church
2017 VACATION BIBLE SCHOOL REGISTRATION
Juicy Fruit: Chew on God’s Word
Vacation Bible School
In this original VBS curriculum, children taste-test the Bible’s stories about fruit, faithfulness, and discipleship. Kids sing, recite Scripture, and exhibit artwork.
*June 26-30, 2017; 9 AM-12 PM
*For Ages 3 years (totally toilet-trained) through 5th grade
*$35 for the week, covers T-shirt & CD
*After care 12-2 PM; $10 per day, per child
*Family Supper & Ice Cream Social on Thursday, June 29; 6:30-8 PM
Register by June 5th
You can pay online or when you drop your children off at camp. Payment must be made at drop off, not pick-up.
If you have more than one child attending, please fill out one form per child and return this form to the church office or email Elyse Milligan at emilligan@eastlakeumc.org.
Child’s Name: ___________________________________________
Date of birth: ____________________________________________
Age: _______
Last grade completed: _________
Camper’s T-shirt size: (please circle) S M L
Address: ____________________________________________________
City: _________________________________
Zip Code: _____________________________
Your email: ___________________________________________
Mother’s Name/Guardian: ________________________________
Phone number: _________________________________________
Father’s Name/Guardian: ________________________________
Phone number: _________________________________________
Emergency Contact Name (In event we can’t reach mom or dad): ________________________________
Emergency Contact Phone Number: __________________________
Will your child need aftercare? (please circle) ($10 per day, per child) Yes No
Would you be interested in volunteering for VBS? (please circle) Yes No
If so, what area? ____________________________________
Frequent Ear Infection______________ Mononucleosis__________________
Hay Fever________________________ Heart Defect Disease______________
Ivy Poisoning______________________ Convulsions_____________________
Chicken Pox_______________________ Bee/Insect Stings_________________
Diabetes__________________________ Measles________________________
Penicillin__________________________ Bleeding/Clotting_________________
German Measles____________________ Other Drugs_____________________
Disorders_________________________ Mumps_________________________
Asthma____________________________ Hypertension____________________
What treatment is required for Asthma ______________________________________
Operations or serious injuries (dates) _______________________________________
Dietary Modifications____________________________________________________
Current Medications (send with instructions) _________________________________
Food Allergies__________________________________________________________
Drug Allergies__________________________________________________________
Other Allergies_________________________________________________________
What treatment is required for allergy?______________________________________
Any other health issues that we should be aware of?___________________________
Date of Last Tetanus Shot________
May adults in charge administer (circle) Aspirin – Y/N Tylenol – Y/N Advil – Y/N
Excedrin – Y/N Aleve – Y/N
Name of Family Physician_____________________________________________________
Address___________________________________________________________________
Number and Street City State Zip
Insurance Coverage
Insurance Company____________________________ Phone ( ) __________________
Policy Number:______________________________________ Group #_________________
I hereby give permission to the Physician selected by the adult in charge of the East Lake United Methodist Church/Children’s Activity to order X-Rays, routine tests and treatment for the health of my child, and in the event that I cannot be reached in an emergency, I hereby give permission to the Physician selected by the adult in charge to hospitalize, secure proper treatment for, and to order injections and/or anesthesia and/or surgery for my child as named above.
Parent or Guardian Signature ____________________________________Date:__________
Photo Video Release
I, as the parent/guardian of ____________________________, herby consent that any photographs or videotape taken while my son/daughter attends East Lake United Methodist Church, or any events associated with East Lake UMC, may be used for print publications, website, and/or videos, to be used within the church and/or to promote the church and its ministries.
__________________________ _________________________ _____________
Signature of Parent/Guardian Printed Name of Parent/Guardian Date
2801 East Lake Road, Palm Harbor, FL 34685 727-784-9250 www.eastlakeumc.org
Revised: March 2017
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