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 VBS Registration-Selbyville Assembly of God
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Child Name *
Child's age
A child's grade is determined by the grade they finished in June 2026.

Name of Parents
Street Address
State
Zip
Home/Cell phone
Emergency contact 
Número de teléfono mó Contacto de emergencia  vil del contacto de emergencia
Home email address
Home Church
Allergies or other medical conditions
Names of people who have permission to pick up
Photo release Photos taken during VBS may be used on Selbyville Assembly of God church website, social media, or in Selbyville Church print collateral. 
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Participation Authorization: I hereby agree and declare that I am the legal parent/guardian of the above-named child and hereby consent to the child's participation in all of the Selbyville Church Rocky Mount VBS activities. 
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Emergency Medical Authorization: I authorize Selbyville Assembly of God church, its staff or its agents, to approve and obtain any and all medical attention deemed necessary for the welfare and good health of the participant(s) when ordered by professional medical staff.  All reasonable attempts will be make to consult with me beforehand.
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Basic Care Authorization:  I give Selbyville Assembly of God church staff permission to administer basic first-aid (i.e: for cuts, scrapes, scratches) in the event my child needs additional medical care, I will be contacted by phone and asked to provide treatment.
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Liability Waiver: I release Selbyville Assembly of God church, its Pastor, Elders, staff and agents from any loss, personal injury, accident, misfortune or damage to participant(s) or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the participant(s).
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Participation Policy:  I understand that Selbyville Assembly of God Church reserves the right to dismiss a participant(s) who displays disruptive behavior, is negatively influencing or is a hazard to the safety and well-being of themselves or others, or who appears to have rejected the reasonable guidelines of the program. 
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