Medical Form

2023 Vacation Bible School

Trinity Presbyterian Church, 1500 Park Blvd, West Sacramento
Monday thru Friday, June 19–23, 6-8 p.m. and Sunday, June 25 10 a.m.
Please have children arrive by 5:55 for Check-in/Registration

Medical Information Form

Complete and submit the following for EACH child attending.
An asterisk * denotes a required field.
All information will remain confidential to the Vacation Bible School staff.

* Indicates required field

Child's Name *

First

Last

Medical Insurance *

Yes No

Medical Insurance Company *

Policy/Group ID *

1) Please list Allergies, Medications and/or Medical Conditions in the space below (if nothing to declare enter "NA").

2) Please list any activity restrictions
in the space below (if no restrictions enter "NA").

1) Required *

2) Required *

Parent/Guardian Phone Number *

Emergency Contact: person(s) & phone numbers in case parent/guardian cannot be reached:

Emergency Contact *

First

Last

Phone Number *

Emergency Contact 2 *

First

Last

Phone Number *

Please list people you authorize to pick up your child in your absence:

Authorized Alternate Pick Up *

Submit