CGCC 2015 VBS Online Registration (VBS注册)

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Theme: Cross Culture, Thailand Trek
Date: Monday, Aug. 24 – Friday, Aug. 28
Time: 9:00 am – 5:00 pm (child care will be available half an hour before and after camp time )
Registration deadline: Sunday, July 26, 2015
Location: China Grace Christian Church, 225 Penllyn Blue Bell Pike, Blue Bell, PA 19422
Fee: $100 / child

Your email (电子邮件) *

Your home address (家庭住址)

Are you a member of CGCC? If yes, which date are you willing to volunteer to help? 如果您是CGCC会员，愿意帮忙么？

(this is optional / 不是必须的)

Mon. 8/24 周一

Tue. 8/25 周二

Wed. 8/26 周三

Thur. 8/27 周四

Fri. 8/28 周五

Other:

Clear selection

Child 1's name 孩子姓名

Sex 性别

Age / Grade 年龄/年级

Birth date? 生日

child's birth date, including year

YYYY

Allergy to? 过敏么？

Does the child allergy to any food or drug? anything else we should be aware of? 有对食物或者药物过敏么？还有什么我们需要知道的信息？

Child 2's name

Sex

Age / Grade

Birth date?

child's birth date, including year

YYYY

Allergy to?

Does the child allergy to any food or drug? anything else we should be aware of?

Child 3's name

Sex

Age / Grade

Birth date?

child's birth date, including year

YYYY

Allergy to?

Does the child allergy to any food or drug? anything else we should be aware of?

Mother's name 母亲名字

mom's phone number 母亲电话

Father's name 父亲名字

dad's phone number

Father's phone number 父亲电话

Emergency contact person's name 紧急联系人

Emergency contact person's phone number 电话？

Release, Permission, and Consent

Please check all of the items below.

I, the undersigned, do hereby agree to release, discharge, and hold harmless China Grace Christian Church, its officers, agents, and employees of and from all causes, liabilities, damage, or demands whatsoever on account of any injury or accident involving my attendance with the VBS program from August 24 to August 28, 2015 and participation in the activities particular to this program.

I hereby authorize a physician(s) selected by the program, or the emergency/outpatient department of the most appropriate hospital to provide such care that includes routine diagnostic procedures and medical treatment as necessary.

I give permission for the program staff at China Grace Christian Church to provide first aid. A photocopy of this authorization shall be considered as effective and valid as the original.

I understand this consent is valid only during the stated dates of the program.

Signature of guardian

Date

YYYY

Submit

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