Child 1 *

First Name

Last Name

Child 2

First Name

Last Name

Child 3

First Name

Last Name

Child 4

First Name

Last Name

Permission for Emergency Care *

I, the undersigned parent/guardian, do hereby grant permission for my son/daughter, named above, to receive the proper medical treatment if he/she sustains injury or illness during the period of VBS/EBC. I hereby authorize the VBS/EBC staff to obtain or provide medical treatment for my son/daughter for such injury or illness during VBS/EBC. The VBS/EBC staff has my permission in an emergency to take my son/daughter, at my expense, to the hospital emergency room deemed appropriate by the rescue squad or the adult advisor(s). The hospital and its medical staff have my authorization to provide treatment, which a physician deems necessary, including anesthesia, for the well-being of my child. I understand every effort will be made to contact me in such a situation.

I Agree

Security Agreement *

Each family participating in VBS/EBC will receive three security cards that show the family identification number. The VBS/EBC staff will release a child to anyone who presents a security card with a family ID that matches the child’s family ID. It is imperative therefore that parents and guardians protect the cards and give them only to people authorized to pick up their children. The VBS/EBC staff will not release a child to anyone that does not have the matching security card, except for the parent or guardian upon presentation of picture identification. I understand the security mechanism being used to protect my child and agree to fulfill my responsibility of protecting the security cards, presenting picture identification when requested, and informing the VBS/EBC staff of anyone who may not pick up my child.

I Agree

Image Notification *

CBC may use photos and videos taken at events in our publications, website and services, but will not identify children in these productions. Images can be taken down at a parent’s request. Please acknowledge by signing below.

I Agree

Electronics Policy *

Cell phones and other electronic devices should be left at home. If a child brings a phone or other device, it will be held for them until they are picked up at the end of the evening.

I Agree

Parent/Guardian Signature *

First Name

Last Name

Date *

MM

DD

YYYY