2024 FaithKids VBS

If you or your child would like to participate in this event as a Participant, please complete the following form.

(If you are under 18, please have your parent or guardian complete the form.)
Personal Information

*Participant's First Name:
*Participant's Last Name:
*Last Grade Completed:
*Parent/Guardian Name:
Primary Phone:
Work Phone:
*Cell Phone:
*Medical Insurance Co.:
*Group Number:
*Policy Number:
*Insurance Co Address:
*Insurance Co City:
*Insurance Co State:
*Insurance Co Zip:
*Insurance Co Phone:
*Physicians Name:
*Physicians Phone:
*Allergies, Medical, & Special Needs:
(Leave Blank if None)
(List all medications taken on a regular basis.)
*Operations and Injuries:
(List all operations - injuries and dates within the past 5 years.)
*Emergency Authorization:
(I hereby give permission to Faith Baptist Church to seek medical attention in the event of an emergency.)

*Financial Responsibility:
(I understand that any and all cost associated with such emergency will be billed to my insurance company and/or myself. Faith Baptist Church has no financial responsibility.)

*Emergency Contact Name (1):
*Emergency Contact Phone (1):
Emergency Contact Name (2):
Emergency Contact Phone (2):
*Authorized Pickup #1:
Authorized Pickup #2:
Authorized Pickup #3:
Authorized Pickup #4:
Are you a member of this church?
Do you attend Church?
If so, where?
May we have permission to photograph your child?
May we have permission to use your child's photograph in church publications?
T-Shirt Size: