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First Burmese Baptist Church of San Francisco
CHILD MEDICAL & LIABILITY RELEASE
2023 VBS ENROLLMENT
PERSONAL INFORMATION:
VBS REGISTRATION INFORMATION:
August 4 – 6, 2023
Child’s Name: ____________________________Tel: _______________________
(Last)
(First)
(M)
August 4 - 6, 2023:
09:00 am to
___
pm
Address: ____________________________________City: ______
____Zip: ______
Gender:____; Age:____; Grade completed: _____
Parent’s/Legal Guardian’s Name:___________________________________
Each application must sign and fill out the form completely.
TEL: (day)_____________; (night) _____________;
Please tear and keep the registration information side of the application for
ANSWER YES OR NO:
your record.
COVID VACCINE:
1st Dose ( ) ( ); 2
nd
Dose: ( ) ( ); 3
rd
Dose ( ) ( )
The contact persons are
:
MEDICAL INFORMATION:
Does Child Have: (check any that apply):
Heart Trouble
Diabetes
Khu Khu Shwe
Tel: 415-710-3037
Lung Trouble
Asthma
Skin Problems
Sinus Infection
Shirley Choo
Tel: 650-238-7830
Delilah Hui
Tel: 707-853-3696
Date of last Tetanus:__________________; Allergic to _______________________
Medication Allergies:___________________________________________________
HOW TO CONTACT YOUR CHILD DURING VBS
:
List allergies and medications taken for control: ______________________________
Address:
First Burmese Baptist Church
List all medication that child may be taking: ______________________________
310, Ottilia Street, Daly City, CA 94014
Dosage:____________________; Pharmacist Phone #__________________________
Emergency Contact Person/Tel#: ______________________________________
EMERGENCY:
Rev. Dr. Latt Yishey:
Tel: 510-754-9275
Please make sure all Meds are turned in to designated personnel upon arrival.
All medication child is presently taking (including over the counter) must be in
original bottle pharmacy indicating dosage, intervals and child’s name.
NOTE: PLEASE
INSPECT CHILD(REN) FOR HEAD LICE OR NITS PRIOR TO VBS. NO CHILD CAN BE
PERMITTED TO REMAIN AT VBS IF THESE ARE PRESENT.
List any activities for health reasons your child cannot be involved in:
___________________________________________________________________
As Parent/Guardian, I hereby authorize and request a hospital emergency staffed
physician to administer any procedure which in their judgment may be necessary. I
also give permission to the First Aid Person to release pre-prescribed medication and
non-prescribed medication such as aspirin.
I release FBBC, and its Sunday School teachers and leaders from any liabilities
that they may have to me or my child(ren) because of my child(ren)’s
participation at the 2018 VBS.
Signed by Parent/Guardian
:
__________________________________
​   
2023 VBS PARTICIPATION CONSENT FORM
I authorize my child(ren) _________________________________ to
attend and participate all sessions of the VBS from
August 4-6, 2023.
The child must be at least 11 years old for sleep over
In addition,
he / she
will sleep over at the FBBC San Francisco,
on Pre-VBS night, Thursday evening, August 3, 2023
.
In addition,
he / she
will also sleep over at the FBBC San Francisco,
during VBS from Friday to Saturday nights,
August 4 - 5, 2023
.
My child(ren) will abide by the rule and regulations of the VBS program.
Signed by Parent:
_____________________________
Date:
_____________________________

 

 

 

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