Name:_______________________ Age:_____ Grade entering:_____

Parent/Guardian Name(s):_______________________________

Address:_____________________________City:_____________Zip________

Phone:______________ E-Mail ______________________

If a T-Shirt is desired, please mark T-Shirt Size ____

(T-Shirts will be available for 10 dollars)

Permission and Medical Authorization

__________________________has my permission to take part in the St. Paul’s Vacation Bible School program.

I hereby authorize any recognized adult leader of this event to give permission for medical treatment after consulting a medical doctor, and making every attempt to contact me as soon as possible. I retain responsibility for any and all bodily injury, loss or damage of

personal property while at St. Paul’s.

_______________________________________________________________________

(Signature of parent/guardian) (Date)

(Emergency phone #)

MEDICAL INFORMATION: Special instructions (medications, food allergies,

etc.)

_______________________________________________________________________

_______________________________________________________________________

Doctor’s Name_________________________________Phone_________________

Insurance Carrier______________________________________________________

Please send your completed registration to

St. Paul’s Lutheran Church

321 N. Park Ave. Medford, WI 54451