Name__________________________________________________________
Current Grade__________________ Date of Birth______________________
Pick-up time ______________________T-Shirt Size____________________
Home Phone__________________________ Alt. Phone__________________
Parents Name___________________________________________________
Address________________________________________________________
Emergency Contact Person ________________________________________
Emergency Contact Person Phone __________________________________
Family Doctor ___________________________Phone___________________
Allergies/Conditions/Medication_____________________________________
Ins Company & Medical Number_____________________________________
How Many for Dinner Adult(s) ___________ Children_________________
Web-Site Waiver
I give my permission for nameless photos to be used on the Church Web-Site.
Medical & Liability Release – Valid August 1-5
In the event of sickness or some medical emergency, I request that my child receive any
medical attention or treatment deemed necessary. Therefore, I give permission to any
hospital, doctor, and/or health care provider to transport, treat and/or admit care for my
child. I understand that I am responsible for all expenses and charges for the treatment
and care of my child. In the event that I am not present at the time of the emergency or
cannot be contacted, my care has been entrusted to the staff and designated ministry
leadership of Watertown Moravian Church.
Signature of Parent or
Guardian_____________________________________________
Date_________________
Watertown Moravian Church 510 Cole St., Watertown 53094
920.261.7494
Mail or Drop off at church office: 510 Cole St.
Watertown Moravian Church Vacation Bible School
August August 1-August 5, 2011
Closing Program August 7 at 10:15 a.m.
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VBS Registration Form