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  • THE WELL FOURSQUARE CHURCH 18325 Horst Avenue Artesia, CA, 90701 United States (map)
Child Info
Child's Name *
Child's Name
Gender *
Date of Birth *
Date of Birth
Parent/Guardian Info
Parent/Guardian Name *
Parent/Guardian Name
Phone *
Alternate Phone *
Alternate Phone
Health Information
Phone *
Last Tetanus Shot *
Last Tetanus Shot
Release Form
As parent/guardian, I give the above child my permission to attend Vacation Bible School at the Well Foursquare Church. In the event of any injury or illness, I authorize the Well staff to provide emergency care from a campus nurse, emergency personnel, or hospital staff in the event that I can not be reached. I verify that the above information is accurate and complete to the best of my abilities. I understand that photos and videos will be taken throughout this event. I release any media to be used by the Well Foursquare Church for promotional purposes.
Date *
Later Event: September 2
Welcome Party