By signing my name below, I do hereby authorize the Woodstock Evangelical Covenant Church to seek emergency medical care for my child(ren) in the event of injury, accident or illness

Parent's Name (required)

Street Address (required)

City/State/Zip Code(required)

Phone Number (required)

Parent's Email (required)

Emergency Contact Name 1 (required)

Emergency Contact Phone 1 (required)

Emergency Contact Name 2 (required)

Emergency Contact Phone 2 (required)

Insurance provider and number(required)

May we have your permission to photograph your child(ren)? (required)
YesNo

Child (1) Name

Child (1) Age

Child (1) Grade

Child (1) Birth Date

Medical/Health/Allergy Concerns (1)

Child (2) Name

Child (2) Age

Child (2) Grade

Child (2) Birth Date

Medical/Health/Allergy Concerns (2)

Child (3) Name

Child (3) Age

Child (3) Grade

Child (3) Birth Date

Medical/Health/Allergy Concerns (3)

I give permission for my child(ren) to be picked up by:

How did you hear about our VBS program?