Emerald Crossing VBS Sign Up

Parent / Guardian Information

First Name *
Last Name *
Email *
Phone Number *
Relationship to Child *

Child's Information

First Name *
Last Name *
Gender*
Male
Female
Date of Birth *
What Grade will your child be entering into? *
Please State any Medical Condition including known allergies to drugs, food, or insects.
Does your child have any medication, epipen, or fast acting inhaler?*
Yes
No
If Yes, what kind?
Does your child have any activity restrictions?*
Yes
No
If Yes, what kind?

Emergency Contact

First Name *
Last Name *
Phone Number *
Relationship to Child *
We are going to be recording for our church and website, are you okay with your Child being filmed or photographed?*
Yes
No
Accept Terms *

We the undersigned, parents of said minor, do hereby authorize Calvary Chapel Fontana as agents for the undersigned to consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act on the Medical Staff of any hospital or medical clinic whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of aforesaid agent to given specific consent to any and all such diagnosis, treatment of hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code 3 of California. (Allows parents or Guardian to authorize any adult to consent to medical or dental treatment as stated in paragraph No. 1 above). This authorization shall remain effective until July 25, 2026 unless sooner revoked in writing delivered to said agent.

Signature of Agreement with Term *
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