2021 KPCB VBS

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

Are you looking for a church?

YES

How did you hear about us?

My Church

Poster Advertisement

Through a Friend

I have attended before

Other:

MEDICAL INFORMATION

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

Does your child have any medical/special needs, including medications currently used?

YES

Health Insurance Company and Policy/Group Number

LIABILITY RELEASE

Signature

By electronically signing below, I, parent or guardian of the above student(s), 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 VBS July 29-31.

Date