Bridgewater United Methodist Church

  651 Country Club Road   Bridgewater NJ 08807

908-526-1414    www.bridgewaterumc.org

       Vacation Bible School

   August 2-6, 2010 -  9:00 am – noon

Family Nite – Thursday, August 5 – 6:30 – 8:30 pm

Please fill out one form for each child.

Please enclose a $15.00/child registration fee ($20.00 after July 1).

Checks may be made payable to BUMC, please but VBS in the memo field.

Questions: Contact Rev. Christina Zito - 526-1414 ext. 6

Child’s Name:  ____________________________________________               ___Male  __ Female

Parent/Guardian Name: _____________________________________________________________

Address: _________________________________________________________________________

E-mail Address: ___________________________________________________________________

Phone Numbers:   Home_______________ Cell _______________     Work _________________

Age information (4 years – thru entering 5th grade):   

              Date of Birth ________________________                  Age _______

              School grade entering ___________________________________

Home Church:  ___________________________________________________________________

Allergies/ Medical/Other Helpful Information: ___________________________________________

_________________________________________________________________________________

________________________________________________________________________________

Emergency Information:

              Emergency Contact Person (if above can not be reached)

            Name ___________________________________                     Phone ____________________

              Doctor’s Name___________________________________   Phone ____________________

              Health Insurance Policy Name _______________________  Policy # __________________

Name of person (other than parent/guardian) who may pick up this child from VBS each day:

              Name ________________________________            Phone ____________________

Parental permission for hospital/emergency care (please sign):

As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care.  I understand that I will be responsible for all charges not covered by insurance.  I give consent for the emergency contact person listed above to act on my behalf until I am available.

              _____________________________________________________           ____________

              (Parent Signature)                                                                                              (Date)