YOUTH Emergency Contact Form    Please Print, Fill out and bring to VBS

Berea Baptist Church Emergency Contact Form

Ward(s) Names and Ages_________________________________________________________________________________ ___________________________________________________________________________________________________________

Address_____________________________________________________________________________________________________

Guardian name ________________________________________________________________________________________

Phone number for Guardian__________________________________________________________________________________

Other emergency contact name and phone number__________________________________________________________________

Any Dietary requirements? (vegetarian, gluten free, lactose intolerant)____________________________________________________ ___________________________________________________________________________________________________________

I give permission for my ward to take part in Berea Baptist Church Activities and agree that the Leadership team of Berea Baptist Church will not be held responsible for any injuries or illnesses that my ward sustains at a Berea Baptist Church Activity. I hereby authorize an adult leader of Berea Baptist Church, to act as an agent of myself, in seeking emergency medical treatment, if deemed necessary for my ward(s). In the event that I cannot be contacted in an emergency, I authorize the physician or hospital selected by the leader to provide treatment, including hospitalization, for my ward(s). 

I also surrender my wards legal right to their electronic image, and permit usage of it/them for in house presentations/ or on our website.

Guardians Signature_____________________________________________Date___________________