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'23 VBS (Form 2 - Participant Info and Medical Release)

You must complete a Medical Relase Form for EACH child attending VBS.

After you submit one, you will have the option to submit another. 

Health Information

Medical History of Child 

If the the answer is no to any of the following questions, please leave the response blank. 

Has your child ever had any of the following?
Answer Required
Are there any known allergies including any allergies to medicine?
Answer Required
Does your child have a prescription for use of any of the following:
Answer Required
Does the child have either of the following medical conditions? (Please check each box if yes).
Answer Required
Does your child wear any of the following?
Answer Required
My child has permission to be given Tylenol, Ibuprofen, Benadryl, or other medications brought from home as prescribed. *
Answer Required

Please note: Your child will not be able to participate in the VBS program if he/she has any of the following symptoms: 

- Fever or Chills, Shortness of breath or difficulty breathing, Vomiting, Diarrhea, Fatigue, Coughing, Body Aches, Headache, Sore Throat 

Physician and Medical Insurance

Please write "none" in the text boxes below if you do not have a physican or have medical insurance

Informed Consent to Medical Treatment: I request that in my absence the above-named minors be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

Consentimiento informado para tratamiento médico: Solicito que en mi ausencia, se admita al menor previamente citado, a cualquier hospital o establecimiento médico para diagnóstico y tratamiento. Solicito y autorizo los médicos, a los dentistas y otro personal debidamente acreditado, Doctores en Medicina o Doctores en Odontología u otros técnicos y personal de enfermería acreditados, para que realicen cualquier procedimiento de diagnóstico, tratamiento o procedimiento quirúrgico y tratamiento de rayos X, que el menor previamente citado necesite. No se me ha dado ninguna garantía con respecto a los resultados del examen o del tratamiento. Autorizo al hospital o al establecimiento médico que disponga de cualquier espécimen o tejido tomado del menor previamente citado. Asumo plena responsabilidad por todos los costos de ese tratamiento. Además, si fuera necesario que el participante regresara a casa por razones médicas, disciplinarias o de cualquier otra índole, asumo por medio del presente instrumento toda responsabilidad para el transporte del participante a casa y los costos relacionados con dicho transporte.

Parent or Legal Guardian Signature and Date/Firma del padre o de la madre o del guardian legal y Fecha *
Signature Required

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By pressing “Sign Form,” you are agreeing to signing this form electronically.
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A copy of this form must be sent to your email: 

Confirmation Email