Pohick Episcopal Church
Vacation Bible School
July 11 - 15, 2005

REGISTRATION FORM

To be held at: Pohick Episcopal Church
9301 Richmond Highway, Lorton, Virginia 22079

For chidren age 3 (only if potty-trained) through Grade 5*
Monday - Friday • 9:00 am - 12:00 noon

IT IS NECESSARY FOR THE DAILY SESSIONS TO BEGIN PROMPTLY AT 9 A.M.

If you would like to help our Christian Education budget,

a donation of $15.00 per family would be most appreciated.

Directions: Please fill out a separate form for each child attending.

Child’s Name_____________________________________________________________________________

Address__________________________________________________________________________________

Telephone _____________________________________ Date of Birth _______________________________

*School Grade completed in June of 2005 ________________________________________________________

Parents' Names ___________________________________________________________________________

Medical Information (e.g. food allergies, etc.) ______________________________________________________

__________________________________________________________________________________________

PLEASE CHECK WHERE APPROPRIATE:
_____ I can stay and help if needed.
_____ We would like to carpool, if possible.
_____ My child would like to come, but will need a ride.
_____ I can provide a ride for _____ child(ren).

PERMISSION FOR EMERGENCY CARE

Name of Child____________________________________________________________

Date of Birth_____________________________________________________________

Name of Parent/Guardian ___________________________________________________

Address____________________________________________________________________________

Telephone_________________________________________________________________________

“THE CHURCH HAS MY PERMISSION TO CALL ANOTHER PHYSICIAN IN AN
EMERGENCY WHEN FAMILY PHYSICIAN OR I CANNOT BE CONTACTED."

Name of Family Physician __________________________________________________

Telephone _____________________________________________________________

IS YOUR CHILD: ALLERGIC TO MEDICATION? ________________________________

IF SO, WHICH __________________________________________________________

ANY OTHER ALLERGIES - SUCH AS BEE STINGS _____________________________

_________________________________________________________________________________________

UNDER PHYSICIAN’S CARE? _________________

UNDER MEDICATION NOW? _________________

“THE CHURCH HAS MY PERMISSION, IN AN EMERGENCY WHEN I (OR MY PHYSICIAN) CANNOT BE CONTACTED, TO TAKE MY CHILD TO THE EMERGENCY ROOM OF THE NEAREST HOSPITAL AND ITS MEDICAL STAFF HAVE MY AUTHORIZATION TO PROVIDE TREATMENT WHICH A PHYSICIAN DEEMS NECESSARY FOR THE WELL BEING OF MY CHILD.”

NOTE: By law a parent cannot consent in advance to any and all manner of emergency care. It is understandable that in cases, other than the need for immediate emergency treatment, the attending physician may defer treatment pending the parent’s permission to administer professional service.

_____________________________________________________________
(parent/guardian signature)

_____________________________________________________________
(date)

Please return this form to the church office, either in person or by mail (address listed above).