Pentecostals of Peoria

Vacation Bible School

ages: 4-11


July 18: 6:30 - 8:30 PM

July 19: 6:30 - 8:30 PM

July 20: 6:30 - 8:30 PM


*Snacks will be provided nightly*

*Please try to be on time to pick up your children*

Child Information *
Child Information
Address *
Parent/Guardian Information *
Parent/Guardian Information
Contact Number *
Contact Number
Emergency Contact Number *
Emergency Contact Number
List all known medical conditions / allergies and over-the -counter or prescription medications taken regularly. Physician’s Name and Number. Is there any other information you feel should be known in advance concerning your child(ren). If yes, please explain.
In the event of an emergency or non-emergency situation requiring medical treatment, I, the above listed parent / guardian, hereby grant permission for any and all medical and / or dental attention to be administered to my child in the event of any accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and / or surgery, under the recommendation of qualified medical personnel. I release and waive any claim I may have against The Pentecostals of Peoria , or the individual members, agents, employees and representatives of either entity, as well as trip supervisors and drivers for any losses, damages, or injuries arising out of, during, or in connection with the participation of the student named herein in the 2018 POP Vacation Bible School or the rendering of emergency medical procedures or treatment. By signing this statement, I affirm the information of this form is correct, agree to all consents and waivers, and hereby grant permission for the student named herein to participate in the 2018 POP Vacation Bible School. Type name here: