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VBS Registration
Name of Child *
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Gender *
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Parents/Guardians *
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Address *
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Best email *
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Birth date *
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Grade this fall *
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If 6th grade or up, please select a helper option
Best phone *
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Second phone
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Emergency contact information *
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Does the child attend Sunday school or CCD? *
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If yes, where?
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my child would like to be placed in a crew with
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I can help staff VBS on
Participant's Physician's Name *
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Hospital/Clinic and Address *
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Participant is allergic to:
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Please list any restrictions on diet or exercise
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Please list any special needs or medical history
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Are there any over-the-counter medications the participant CANNOT receive?
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Is the participant on regular medication? If so, please list the drugs, dosages, frequency and any instructions
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Will the child be attending Afternoon Adventures? *
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Person responsible for picking up child at the end of each day:
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Phone number for responsible person
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My child has permission to go to the YMCA swimming pool with the Afternoon Adventures staff
I am a member of the Y
RELEASE OF ALL CLAIMS--I (we) do for myself (ourselves) and on behalf of my child/participant do hereby release, forever discharge, and agree to forever hold harmless St. John’s Lutheran Church and the Southeastern Pennsylvania Synod, ELCA, the employees, and agents thereof, from any and all liability, claims and demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by me or my child/participant resulting from said child’s participation in the synod sponsored youth events, including travel, recreation and all associated activities. Further, I (we) (and on behalf of our child/participant under 18 years of age) hereby assume all risk of said personal injury, sickness, death, damage and expenses as a result of participation as above set forth. I also understand that staff and volunteers are not responsible for the administration of prescribed medication and I (we) have made private arrangements for any medication taken on a daily schedule by my child/participant. I (we) am (are) the parent(s) or legal guardian(s) of this participant, and herby grant my (our) permission for him/her to participate fully in said youth events, and give my (our) permission to take said participant to a doctor or hospital, share the above medical information and authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and assume responsibility of all medical bills incurred by my child. I (we) give permission for the participant to receive over the counter medication such as Tylenol, ibuprofen, antidiahhreal medication, antibacterial ointment, throat lozenges, eye wash solution, and the like. I (we) also release the participant’s name as part of an information database for the church, synod and ELCA related entities. I (we) also grant St. John’s, the synod and ELCA unrestricted rights to use, alter, and reproduce any images (still and video) from the event, in any medium without compensation. I agree/disagree by clicking "yes" or "no" below and this may be accepted as my legal signature. *
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Date *
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