Vacation Bible School Medical/Media Release Vacation Bible School Medical/Media Release June 17 through June 20, 2024 – 9a.m. until Noon at Blessed Sacrament Catholic Church (3109 Swede Ave) Participant/Volunteer InformationName First Last Select One Participant Volunteer List allergies, medication, or pertinent medical information the coordinator should know: Name First Last Select One Participant Volunteer List allergies, medication, or pertinent medical information the coordinator should know: Name First Last Select One Participant Volunteer List allergies, medication, or pertinent medical information the coordinator should know: Name First Last Select One Participant Volunteer List allergies, medication, or pertinent medical information the coordinator should know: Emergency Contact InformationName(Required) First Last Phone(Required)Email(Required) Enter Email Confirm Email Medical Insurance Carrier Policy/Contract Number Family Physician Physician PhoneRelease InformationMedical: In case medical treatment is necessary and the emergency person cannot be located, the following authorization is needed, I (We) authorize the adult advisor in charge to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above-named adult/minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the state of Michigan. Medicines that need to be dispensed during this activity must be given to the designated supervisor in its original container with directions and dosage.Medical ReleaseMedical: In case medical treatment is necessary and the emergency person cannot be located, the following authorization is needed, I (We) authorize the adult advisor in charge to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above-named adult/minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the state of Michigan. Medicines that need to be dispensed during this activity must be given to the designated supervisor in its original container with directions and dosage. I agree to the medical release.Media ReleaseMedia Release: During the course of the program church staff or volunteers will be taking photos, videotaping and/or voice recording individuals. This media may be displayed on our parish’s website or be distributed to enrolled children’s parents for their own personal use. Enrolled children’s parents or other relatives often take photos and/or videos during the VBS. Please sign acknowledging fact. I agree to the media release.SignatureDate Month Day Year