VBS Medical Release Form:

Parent Name *

First Name

Last Name

Phone *

(###)

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Child Name *

First Name

Last Name

Child Name #2

First Name

Last Name

Child Name #3

First Name

Last Name

Child Name #4

First Name

Last Name

Doctor's Phone Number *

(###)

###

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Parental Consent *

I authorize the leadership of CHRIST PRESBYTERIAN CHURCH to care for the administration of first-aid treatment for any minor injuries my child receives during the event. If the injury sustained is life-threatening, or in need of emergency treatment, I authorize the leadership of CHRIST PRESBYTERIAN CHURCH to summon any or all professional emergency personnel to attend, transport, and treat my child. I agree to hold harmless any staff, assistants, and volunteer workers of CHRIST PRESBYTERIAN CHURCH from any and all claims, suits, costs, and actions of any kind whatsoever, arising from their exercise of the power granted by this authorization. I give permission for the above named child (children) to be photographed during VBS, and for the images to be published, reproduced or distributed by Christ Presbyterian Church in all outlets, including, but not limited to, internet and church publications, without liability or limitation on my or my minor’s part.

Yes

No