2019 VBS Registration — Gospel Life Fellowship

Student 1 (NAME, BIRTHDATE, GRADE IN FALL)

Student 2 (NAME, BIRTHDATE, GRADE IN FALL)

Student 3 (NAME, BIRTHDATE, GRADE IN FALL)

Parent/Guardian Name

Phone Number

Address

MEDICAL INFORMATION

Allergies (If more than one child, please write child's name next to allergy)

Health Insurance Company and Policy/Group Number

LIABILITY RELEASE

By electronically signing below, I, parent or guardian of the above students, authorize adult leaders of of Korean Presbyterian Church of Baltimore as agent(s) for the undersigned, to consent to medical care deemed advisable by an accredited physician or surgeon in an approved emergency clinic or hospital if I am not able to be reached. I release from any liability Korean Presbyterian Church of Baltimore, any of its ministers or leaders in the event of an accident during KPCB Summer Program (Power Walk,VBS) 2019, from 7/19-8/23 (Power Walk, every Fri.) and 8/6-8/10 (VBS).

Electronic Signature

Date

2019 Children’s Summer Program Registration