(Print this page, fill it in, and bring it to the first VBS meeting.)
Name___________________________________ Age_____ Last grade completed_______
Address_____________________________________________ Birth date_____________
____________________________________________________ Phone_______________
Parents or Legal Guardian_____________________________________________________
Emergency Contact Person (if other than listed above)
____________________________________________________ Phone_______________
Known Allergies____________________________________________________________
Family Doctor_____________________________________ Dr. Phone_________________
In the event of an emergency, I give my permission for ___________________________to receive medical treatment if I, or the above mentioned persons, cannot be reached.
Signature_______________________________________________
Maintained by Richard L. Bowman (email: rebowmanmail@gmail.com ). Last modified: 27-Jun-09.