VBS Registration | Faith Evangelical Presbyterian Church

How many children do you need to register?
Child 1 Information
Child's Name*
First Last
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Grade in the Fall
Name of School
Allergies
Child 2 Information
Child's Name
First Last
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Grade in the Fall
Name of School
Allergies
Child 3 Information
Child's Name
First Last
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Grade in the Fall
Name of School
Allergies
Child 4 Information
Child's Name
First Last
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Grade in the Fall
Name of School
Allergies
Parent/Guardian Contact Information
Yes parent attending (Choose one or both)*
- Dinner
- Parent Gathering
Parent/Guardian 1 Name
First Last
Parent/Guardian 2 Name
First Last
Phone Number
Emergency Phone Number
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What church do you attend?
Are you a member?
- Yes
- No
Persons authorized to pick up my child/children:
Medical Information & Release
Do you have medical insurance?*
- Yes
- No
Insurance Company
Policy/Group ID#
Medical Treatment Permission*
- Yes, I understand and give permission
We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.
Liability Release
Liability Release*
- Yes, I understand and give permission.
In consideration of Faith Evangelical Presbyterian Church allowing the above child to participate in Vacation Bible School activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless Faith Evangelical Presbyterian Church, its directors, employees, volunteers and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above child while involved in Vacation Bible School. Furthermore, we (I) [and on behalf of our (my) minor child(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in activities involved therein.
Media Release
Media Release*
- Yes, I understand and give permission
I hereby give permission for the staff and volunteers of Faith Evangelical Presbyterian Church to photograph, videotape and/or voice record my child/children (or allow area news reporters to do the same) for purposes of in-house church use and/or for public information for promotion of the church (i.e. brochures, websites, newspapers, radio, television).
Signature
Parent/Guardian Signature*
First Last
Date*
MM slash DD slash YYYY

Child 1 Information

Child 2 Information

Child 3 Information

Child 4 Information

Parent/Guardian Contact Information

Medical Information & Release

Liability Release

Media Release

Signature