SHBF Vacation Bible School - Registration Form

Please fill out this form, then print and mail it to:
South Hills Baptist Fellowship
PMB 2171, 1 Jackson Creek Rd.
Clancy, MT 59634


Name:
Parents:
Address:
City, State, Zip:
Home Phone:  Cell:
Age:  Last Grade Completed:  Birthday:
Do you go to Sunday School?   Yes No   If so, where?:
Who may pick up this child?:   Phone:
May we have permission to photograph your child?   Yes No       T-Shirt Size:
May we use your child's photograph in church publications?   Yes No



MEDICAL INFORMATION:
Does this child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition,
history of respiratory illness or any other significant medical condition? Yes No


FAMILY DOCTOR CONTACT INFORMATION:
Family Doctor's Name:  Phone:



EMERGENCY AUTHORIZATION:
I, the undersigned parent or legal guardian of the participant, hereby authorize the SHBF Vacation Bible School staff acting
in the capacity of activity supervisors, as my Agents, to consent to medical, surgical, or dental examination and/or treatment.
In case of emergency, I hereby authorize treatment and/or care to any hospital. If there is an emergency and I cannot
be reached, I hereby appoint the following individual to act on my behalf:


Full Name:
Address:
City, State, Zip:
Home Phone:  Other Phones: