The Lutheran Church of the Triune God - PLEASE FILL OUT COMPLETELY

Brooklyn Center, Minnesota - ONE FORM PER FAMILY, PLEASE

Vacation Bible School

Child's Name: _____________________________________________ Age: ______ Grade in School (2011-12) _______

_____________________________________________ Age: ______ Grade in School (2011-12) _______

If food allergies, or other medical concerns, please list for each child: ___________________________________________________

__________________________________________________________________________________________________

Parents/Guardians: ___________________________________________________________________________________________

Address: ___________________________________________________________________________________________________

Home Phone Number: ____________________________ Cell or Alternate Phone Number: ___________________________

Emergency Contact Person: ___________________________________ Phone Number: ______________________________

Doctor: ___________________________________________________ Phone Number: ______________________________

Church Home (if other than Triune God): _________________________________________________________________________

My child(ren), listed above, has my permission to attend Vacation Bible School at The Lutheran Church of the Triune God, 5827 Humboldt Ave. N., in Brooklyn Center, Minnesota, June 20-23, 2011. I give the VBS and/or church staff of The Lutheran Church of the Triune God permission to administer first-aid and/or to secure medical treatment for my son(s)/daughter(s) in the event of a medical emergency.

____________________________________________ _________________________

Signature of Parent or Legal Guardian and Date