West Hills Christian Church
Vacation Bible School

Online Registration and Parental Consent Form

If you have questions or need help, please contact us (the contact page will open in a new window)

We (I) hereby give our (my) consent for West Hills Christian Church, who will be caring for our (my) children (child) listed below during the week of Vacation Bible School (July 17 - July 21, 2006) to arrange for routine or emergency medical/surgical/dental care and treatment necessary to preserve the health of my (our) children (child).  We (I) acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.

I certify that I am the parent/guardian listed on this form, and that all information is accurate to the best of my knowledge.  I have read and agree to the above terms.

Full Name Age Birth-date
(mm/dd/yy)		 Grade Completing

(if you need to register more children, you will need to repeat this process starting from the main VBS page)

Parent/Guardian Name:
Mailing Address:
Home Phone
(Ex: 4121234567)
Please list any phone numbers that you can be reached at in the event of an emergency
E-mail address
(enter the address that we should send your confirmation to--please only enter one)
Family Physician
Physician Phone Number
Name of Health Insurance Carrier
Policy Number:

Please list any additional information, including medications your child is taking and any allergies or medical conditions your child may have.

By clicking "submit," I certify that I am the parent/guardian listed on this form, and that all information is accurate to the best of my knowledge.  I have read and agree to the above terms.

Please only click submit once.  We will send a confirmation E-mail to the address you provided above.