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Mission from God VBS Registration 
St. Theresa Parish Hall ..........June 24-27..........8:30-11:30am  
For students entering grades K-5 in the fall of 2024
Volunteers 6th grade through adult, please contact Janis or Jane Ann
St. Theresa Parish Hall  1230 Merle Hay Rd.  Des Moines, IA 50265
Jane Ann Becicka (515) 279-4654 x304 
Janis Falk (515) 255-1175 x210
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Email *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Best email address *
Parent/guardian's  phone during VBS *
#1 Child's First Name *
#1 Child's  Last Name *
#1 Child's grade in the fall 2024 *
# 1 Child's Special Needs-medical & behavioral (e.g. food allergies, asthma, sensory issues, etc.) *
#2 Child's First Name
#2 Child's Last Name
#2 Child's grade in the fall
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# 2 Child's Special Needs-medical & behavioral (e.g. food allergies, asthma, sensory issues, etc.)
#3 Child's First Name
#3 Child's Last Name
#3 Child's grade in the fall
Clear selection
# 3 Child's Special Needs-medical & behavioral (e.g. food allergies, asthma, sensory issues, etc.)
Additional children's names, grades and special needs.
Vacation Bible School fees are due on the first day of VBS.  $35 for first child;  $25 for second child and $15 for each additional child.  Checks may be addressed to St. Theresa Parish or you may pay through the parish giving portal. Payment Portal for VBS/Faith Formation            *
Catholic Diocese of Des Moines Permission to Publish In an attempt to share information concerning the outstanding accomplishments of our youth, we may write articles, produce videos, and provide pictures for publication in various media.  To include your child and his/her work in this publicity, we must have your written permission.  You have the right to revoke permission at any time.  Please Check Below: *
Medical Permission for Youth: I grant permission, that in the event my child is injured or becomes ill, for medical care to be administered to my child and to use our personal insurance to cover such incidents.  I hereby give permission to the physician selected to render medical treatment deemed necessary and appropriate by the physician. *
Insurance Information:   (1)Insurance Company; (2) Name on Policy;  (3)Policy Number *
Emergency Contact First Name *
Emergency Contact Last Name *
Emergency Contact's Phone Number during VBS *
Release of Liability for Youth and Adults                               I understand all reasonable safety precautions will be taken at all times by St. Theresa Catholic Church and its agents during the events and activities.  I understand the possibility of unforeseen hazards and know the inherent possibility of risk.  I agree not to hold the Catholic Diocese of Des Moines, St. Theresa Catholic Church, &/or St, Augustin Parish, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subjects of this form. *
Name & phone # at time of VBS for all people who will pick up your child if different than parent/guardian and emergency contacts.
Anything else that we should know to help your child(ren) have a joyful experience?
Volunteers make VBS possible.  We have roles for middle school-adults behind the scenes and with the participants.  Are you or someone in your home available to help for any or all of VBS? If so, check "Yes" and we will be in touch.  Thank you!
A copy of your responses will be emailed to the address you provided.
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