Vacation Bible School

Student #1-First and Last Name
Student #1-Grade 2023-24 School Year (Grades 1-6)
Allergies or Medical Conditions?
Address, city, state, zip code
Parents Name(s)
Parents Email
Parent cell phone
Phone to call DURING Vacation Bible School
Secondary emergency contact and phone number
Student #2- Name and Grade 2023-24
Allergies or Medical Conditions?
Student #3 - Name and Grade 2023-24
Allergies or Medical Conditions?
Medical Authorization: By checking this box I grant permission for the administration of First Aid to the participant by the people in charge of Maternity BVM VBS as their judgement deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand that I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the emergency contact of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff/volunteer to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for the child.
Hold Harmless: By checking this box, I agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend Maternity BVM, the Diocese of Joliet, its officers, directors, agents, employees, or representatives from any and all liability for illness or death arising from on in connection with my participation in MBVM events. In the event that I should require medical treatment and I am not able to communicate my desires to attend physicians or other medical personnel, I give permission for the necessary treatment to be administered.

Vacation Bible School

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