Date Registration Received Initial

Cash Amt $ / Check # Amt

T - Shirts RecievedFor Church Use Only

XS S M L XL

I, as the parent or guardian of , GRANT permission to my child to participate in Naperville & North Chicago Onnuri Church 2012 VBS Program. In the event of a medical emergency while my child is participating in VBS Program, I authorize Naperville & North Chicago Onnuri Church

use the contact information provided below to contact me in the eventof such emergency. If any emergency medical procedures or treatment are required during the trip, I consent to the trip supervisor(s) arranging for and consenting to the procedures or treatment in the supervisor s discretion. I will pay the costs of any such medical procedures or treatments.

저는 의 부모 및 법적보호자로서 우리 아이를 네이퍼빌 시카고와 노스 시카고 온누리교회에서

주최하는 2012년 여름성경학교에 참가하는 것을 허락합니다. 만약 여름성경학교에 참가하는 동안 응급상황이 발생할

경우, 네이퍼빌 시카고와 노스 시카고 온누리교회에서 의료보험과 치료에 필요한 정보를 제공하는 것에 대해 동의하며

교회 담당자에게 응급상황시에 필요한 조치에 대한 결정권을 위임하고 비용을 지불하는 것에 동의합니다. 마지막으로

응급상황 발생시 네이퍼빌 시카고와 노스 시카고 온누리교회가 부모님이나 법적보호자, 또는 제가 지정한 사람에게

연락해 주는 것에 동의합니다. (**의료보험과 치료에 필요한 건강정보는 따로 작성해주셔야 합니다)

Parent / Legal Guardian Name : Date : Signiture :

7/31 (Tue) ~ 8/2 (Thur) 10am ~ 3pm

Registration Form(One form per child)

Child Name

Date of Birth

Parent / Guardian Name

Address

Home # Cell # Home Church (Name, Town) As a parent would you like to volunteer at VBS? Yes / NoIf yes, volunteer Name & Phone # Allergies / Other Medical Conditions

Special friend your child wants to be with during VBS

Naperville and North Chicago Onnuri Church VBS

Naperville Chicago & North Chicago Onnuri Church VBS

7/31 (Tue)~8/2 (Thur) 10am ~ 3pm

Registration Form - Part 2(One form per child)

Emergency Contact Information1st Choice Name: __________________ Phone: _______________2nd ChoiceName: __________________ Phone: _______________

Emergency Medical Information (Please complete as applicable.)

Family Physician: _________________________

Phone Number: _________________________

Date of last tetanus booster: ___________________

My child is allergic to: ___________________

Medication taken routinely: ___________________

___________________________________________

Special health needs: _________________________

___________________________________________

Name of insurance company:

___________________________________________

Policy #: _______________________________