MEDICARE/INSURANCE INFORMATION
Medicare #: Insurance company: Policy #: Subscriber’s name
Prov.:
In case of emergency contact: NAME: PHONE:
area code: (
)
has my permission to go to New Brunswick Bible Institute, Victoria Corner, NB on November 6-7, 2015. NBBI has my permission to obtain emergency medical treatment should an emergency arise during his/her stay. Parent’s Signature
Date
November 6-7, 2015
Year
quest
Month
/ Asthma / Other Respiratory Problem / Heart Trouble / Diabetes / Convulsions / Appendicitis / Bed wetting / Sleep walking Does your child have any other problems that we should know about? / Your child’s last tetanus shot date
kids
MEDICAL HISTORY
Does your child have any known allergies? Yes No What are they? Bee Stings Penicillin Other Drugs Foods Other Does your child take any daily medications? Yes No List medications, what they are for and when they are to be taken. Date of last occurrence Does your child have a history of:
Every year, the campus of New Brunswick Bible Institute is flooded with kids for a whirlwind weekend of fun. Join us again this year for Kids’ Quest! There will be lots of fun activities, singing, Bible lessons, and swimming at the Woodstock Civic Centre.
on NOV 6-7, 2015 for GRADES 2-6
$
35
cost
registration Nov 6 @ 6:00 pm atlantic time pick up
4
:00 pm Nov 7
bring notebook & pen modest swimsuitBible sleeping bag & pillow change of clothes toiletries appetite
’
kids quest
New Brunswick Bible Institute 2335 Route 103 Victoria Corner NB E7P 1C7 (506) 375-9000 - retreats@nbbi.ca
Please DO NOT mail to our US address. If mailed from the US, sufficient postage to Canada must be added!
Name: Birthdate:
/
/
YY / MM / DD
Grade:
Sex: M F
Address: City Code
Prov/State
Phone: (
)
Email: Pastor’s Name: Home Church: Name of group of retreaters you will be with:
Please visit our website at nbbi.ca/kidsquest for additional information, including leader and driver information, or to apply online.
NBBI student you would like to room with (if any):
All leaders must register. The fee for leaders is only $15.
Retreater you would like to room with (if any):
To attend Kids’ Quest you must be in GRADES 2-6
For office use only Number # Date sent Registration fee of $35.00 paid by: Paypal Visa Mastercard Cash Cheque accepted not accepted acknowledged email