2026 Summer VBS

Parent's Name

First NameLast Name

Parent's Name

First NameLast Name

Parent's Email

example@example.com

Parent's Mobile Number

Area CodePhone Number

Child's Name

First NameLast Name

Child's Birthdate

Date

Child's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Gender

School Child Attends

Example:

Child's Grade

I, the parent or legal guardian of above mentioned child, warrant that I possess all the rights, powers and privileges of a parent or legal guardian necessary to execute this legal instrument with binding legal effect.

As a parent or legal guardian of above mentioned child, I certify and affirm that I have been completely and thoroughly informed that as a youth attending Dothan 1st Assembly of God (known as Dothan 1st), my child may participate in certain activities which carry with them a degree of risk and danger.

Examples of risky and dangerous activities include, but are not limited to:

1. physical activities, both indoors and outdoors

2. sports, both informal and organized

3. use of recreational equipment

4. field trips, both on and off campus

5. travel by automobile

6. activities around water

I acknowledge and understand that Dothan 1st may offer other activities not listed above that present similar risks or dangers to my child.

I consent to my child’s participation in these activities. I acknowledge and understand that this PARENTAL CERTIFICATION, CONSENT AND RELEASE has the same force and effect regardless of whether the activities engaged in are free or if a fee is charged.

Further, I personally assume, on my child’s behalf, all risk in connection with said activities for any harm, injury or damages that may befall my child as a result of my child’s participation in the activities, whether foreseen or unforeseen, and I still wish to allow my child to proceed with the activities.

I acknowledge and agree that Dothan 1st shall not be held liable in any way for any occurrence resulting directly or indirectly from these activities that result in injury, death, or any damages to my child, me, or my family, heirs, or assigns. In consideration of my child being allowed to participate in these activities, on behalf of my child, I hereby personally assume all risk in connection with said activities, for any harm, injury, or damage that may befall my child, me, or personal injury me or my family, heirs, or assigns while engaged in such activities.

I understand that the terms herein are contractual and not mere recital; I have signed this document as my own free act. It is my intention by signing this document to exempt and release Dothan 1st Center from all liability whatsoever for personal injury, property damage or wrongful death caused by negligence.

I further acknowledge and agree that my signature on the PARENTAL CERTIFICATION, CONSENT AND RELEASE shall constitute a bar to any recovery by my child, me, or my family, heirs, or assigns in all suits and actions that may be instituted against Dothan 1st, its agents, servants or employees for injuries or death to my child, whether or not same resulted from the negligence Dothan 1st, its agents servants, or employees, or due to the negligence of my child or due to the risks ordinarily incident to my child’s participation in these activities, or due to the contributory negligence of my child.

I understand that it is my obligation to inform the management of Dothan 1st of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities involving Dothan 1st or its programs.

I have fully informed myself of the consents of this PARENTAL CERTIFICATION, CONSENT AND RELEASE by reading it before I signed it.

Parental Consent: Parent/Guardian Signature

Date of Signature

Date

Child's Date of Birth

Date

Does your child have Health Insurance coverage?

Health Insurance Company

Health Insurance Policy Number

Does the camper have any allergies?

List all allergies, the type of reaction they cause and what treatment to give for said allergy.

Does the camper have an epi-pen? If so, they must keep it with them at all times!

Does the camper have any special food restrictions?

Please list any special food restrictions

Will he or she need to take any medications during Summer Blast?

IMPORTANT: All medications must be in the original package (daily sorters/pill keepers are not permitted.) Then please place medication into a Ziplock bag with child's name and any instructions on it. You'll present this at registration to a leader on the first day of Summer Blast.

List medications and when they must be taken (example: 1 Claritin At Breakfast, At Lunch, As Needed, etc.)

Has the the camper been diagnosed with asthma by a physician?

IMPORTANT: If your child has been diagnosed with asthma by a physician and has medication including tablets, nebulizers, or inhalers, they MUST bring such treatment wtih them to camp or they will not be allowed to stay at camp!

If your child has an inhaler, they must keep it with them at ALL TIMES during camp!

Does the camper have any other significant health history (heart condition, diabetes, any injury) or does the camper have any restrictions/medical conditions that the nurse needs to be aware of?

If Yes, please explain

May we give your child...

Tylenol?

Ibuprofen?

Aleve?

Pepto Bismol?

Tums?

Maalox?

Immodium?

Claritin?

Benadryl?

Tussin Cough Syrup?

Visine?

Neosporin?

Hydrocortisone Cream?

Primary Contact: In case of emergency, please contact the following person

First NameLast Name

Primary Contact relationship to student

Primary Contact Home Phone Number

Area CodePhone Number

Primary Contact Cell Phone Number

Area CodePhone Number

Primary Contact Work Number

Area CodePhone Number

Secondary Contact: In case of emergency, please contact the following person

First NameLast Name

Secondary Contact relationship to student

Secondary Contact Home Phone Number

Area CodePhone Number

Secondary Contact Cell Phone Number

Area CodePhone Number

Secondary Contact Work Number

Area CodePhone Number

I have read and understand the statements in this release form. I understand that should a health problem arise, I will be notified but if I cannot be reached by telephone I consent to emergency medical treatment, which may include surgery for my child as deemed necessary by competent medical personnel. I also consent to the release of information for insurance purposes.

Parent/Guardian Name

First NameLast Name

Parent/Guardian Signature

Summer Blast Camper Payment

1 Camper$85.00

Price is per camper and includes ALL activities, food, and fun!

1 Camper (Pay by Day)$30.00

Price is per camper, per day and includes ALL activities, food, and fun!

Quantity

Total $0.00

Payment Methods

Credit Card

Apple Pay

Cash App Pay

ACH Bank Transfer

If choosing to pay by day, please comment which days your child will be attending.

2026 Summer VBS Day Camp

General Information

Parental Consent

Child's Medical Information

Over the Counter Medications Permitted

Emergency Contacts

Medical Information Signature

Summer Blast Camper Payment

Payment Methods