First Congregational Church of Whitman

August 7^th through 10^th

9:00am-Noon

$20 Registration Fee Per Child (Family max of $40)

Registration Deadline: July 20^th

Theme: Treasure God’s Love (Pirates be among us! YARRRRR!)

Child(ren)’s Name:

Date(s) of Birth:

Age(s):

Grade(s) Entering:

Parent/Guardian Name(s): Address:

Secondary Phone #: Email Address:

Emergency Contact Name: Phone #:

Allergies or Medical Concerns:

I do or do not give permission for my child to be photographed and photos added to FCCW Facebook page.

EMERGENCY INFORMATION AND MEDICAL AUTHORIZATION

Purpose of the following information: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under church authority, when parents or guardians cannot be reached.

In the event reasonable attempts to contact me at (phone #) have been unsuccessful, I hereby give my consent for: (1) The administration of any medical treatment deemed necessary by (physician)

Dr. at phone # or (Dentist) `Dr. at phone# , or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to (preferred hospital) or any other hospital reasonably accessible.

Facts concerning the child’s medical history including allergies, medications being taken and any physical impairments to which a physician should be alerted:

_______________________________________________________________________________________________________

I do not give consent for church authorities to contact any medical professionals in the event of an emergency.

Parent/Guardian Signature:

Date

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Return to First Congregational Church, VBS 519 Washington Street, Whitman, MA with $20 registration fee. Make checks payable to FCC Whitman