Student Age *

Student Grade *

Mailing Address *

Date of Birth

T-Shirt Size *

Parents / Guardian Names *

Special Meal or Food Allergies *

If yes description of food not to serve student.

I therefore release and discharge all liability for any harm or injury suffered directly or indirectly as a result of my child's participation in the Avenue VBS Program, whether or not resulting from negligence. I also give permission for the staff, representative, or volunteers of The Avenue to administer first aid or to seek medical care for my child during my child's participation in the program, including transportation of my child to a medical facility for additional treatment that appears necessary.By checking yes will be your signature to our waiver.

Cell Phone *

Emergency Contact Phone Number

Email Address