East Lake United Methodist Church 2017 vacation bible school registration

Download 82.82 Kb.
Hajmi82.82 Kb.
East Lake United Methodist Churchelumc logo


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? ____________________________________

Health Information

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_____________________________________________________


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

Download 82.82 Kb.

Do'stlaringiz bilan baham:

Ma'lumotlar bazasi mualliflik huquqi bilan himoyalangan ©hozir.org 2020
ma'muriyatiga murojaat qiling

    Bosh sahifa
davlat universiteti
ta’lim vazirligi
O’zbekiston respublikasi
maxsus ta’lim
zbekiston respublikasi
o’rta maxsus
davlat pedagogika
axborot texnologiyalari
nomidagi toshkent
pedagogika instituti
texnologiyalari universiteti
navoiy nomidagi
samarqand davlat
guruh talabasi
toshkent axborot
nomidagi samarqand
ta’limi vazirligi
haqida tushuncha
toshkent davlat
Darsning maqsadi
xorazmiy nomidagi
Toshkent davlat
vazirligi toshkent
tashkil etish
Alisher navoiy
rivojlantirish vazirligi
Ўзбекистон республикаси
matematika fakulteti
pedagogika universiteti
таълим вазирлиги
sinflar uchun
Nizomiy nomidagi
tibbiyot akademiyasi
maxsus ta'lim
ta'lim vazirligi
o’rta ta’lim
махсус таълим
bilan ishlash
fanlar fakulteti
Referat mavzu
umumiy o’rta
haqida umumiy
Navoiy davlat
Buxoro davlat
fanining predmeti
fizika matematika
universiteti fizika
malakasini oshirish
kommunikatsiyalarini rivojlantirish
jizzax davlat
davlat sharqshunoslik