9408 Wilson Ave SW, Byron Center, Mi 49315

(616) 878-1619

Email: parishoffice@stsebastianmi.org

2019 Family VBS Form Page 2

  • As legal guardian, I understand that photos and videos of participants may be taken during this time. I am the parent/guardian of those listed on this sheet, and I hereby approve and consent to the use of his/her photo or video image and name to be used for promotional purposes (bulletin, church website, newspaper, etc.).
  • Please indicate company name, and Contract/Policy/Group Number
  • Family Doctor Name and Phone Number
  • As a parent/legal guardian, I do hereby authorize the treatment for the children listed on this form in the event of an emergency which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me at the telephone numbers listed on this form. I agree to be responsible for all costs and expenses incurred in connection with said medical services. This is intended for the period of June 23-27, 2019 during St. Sebastian Parish Vacation Bible School. I understand that all reasonable safety precautions will be taken at all times by the parish and its agents during VBS. I agree not to hold St. Sebastian Parish, its leaders, employees, volunteers, or the Roman Catholic Diocese of Grand Rapids liable for damages, losses, diseases, or injuries incurred by the aforementioned.