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
:
__________________________________
