2019 VBS Participant Registration
July 29-Aug 2
9am-noon: ages 3-5 / 9am-3pm: entering 1st-6th

First English Ev. Lutheran Church
800 Vernier Rd / 48236

Contact Renata Conger
313-884-5040 x 13 / renata@feelc.org

*registration closes on July 14 at 11:59pm*

Email address *
Child's Name *
Your answer
Prefers to be called (nickname) *
Your answer
Gender *
Grade Entering (in fall 2019) *
Birthday *
All participants must be at least 3-years-old and fully potty trained at program start.
MM
/
DD
/
YYYY
Home Church *
Required
Home Address/City/State/Zip *
Your answer
Parent/Guardian Name(s) *
Your answer
Primary Phone Number *
must format like this: 123-456-7890
Your answer
Alternate Phone Number *
must format like this: 123-456-7890
Your answer
Backup Contact Name & Relationship *
In the event that an above parent/guardian cannot be reached
Your answer
Backup Contact Phone Number *
In the event that the primary and alternate numbers cannot be reached
Your answer
Child may be released to these additional people
Your answer
Describe any MEDICINAL allergies or intolerances (or leave blank if none).
Your answer
Describe any FOOD allergies or intolerances (or leave blank if none).
Your answer
Describe any OTHER allergies or intolerances (or leave blank if none).
Your answer
I affirm that this child is up-to-date on all immunizations recommended by the CDC and AAPA *
This child requires the following medications be taken during VBS; include medication name, dosage, frequency, and purpose (or leave blank if none).
Your answer
Describe any activity restrictions the child must adhere to (or leave blank if none).
Your answer
Describe any recent illness, injury, or infectious disease (or leave blank if none).
Your answer
Describe any behavioral, emotional, or mental health needs of which we should be aware (or leave blank if none).
Your answer
Policies
*Participation* All participants must be at least 3-years-old and fully potty-trained to attend Vacation Bible School (VBS). Students entering 7th grade in the fall (and older) may apply for a volunteer position. Completion of this form after space is full may result in your child being wait-listed; notice of such will be given as soon as possible.

*Personal Devices and Other Valuables* Use of electronic devices such as iPods, hand-held games, and cellphones are prohibited during program hours; their use may result in confiscation until the end of the day. It is encouraged that these and other valuables stay at home as VBS staff and volunteers, and Living Water Ministries (LWM) staff cannot be responsible for lost, stolen, or damaged items.

*Medication* Please send only those medications that absolutely must be taken during VBS (i.e. if it can be taken before or after, please make all efforts to do so). Prescription medication must be in its original container AND clearly labeled with the child’s name, dosage, and storage information. If medication must be taken during program hours, please speak with a VBS staff person prior to the participant’s first day. The program stocks over-the-counter medications for pain, upset stomach, diarrhea, allergies, etc. to be administered at the discretion of the Health Officer. Please do not send over-the-counter medications unless the participant is taking them regularly.

*Behavior* VBS and LWM expect Christ-modeled behavior (respect of oneself and others) from anyone visiting or attending the premises. These expectations are reviewed with participants each day. Failure to follow these expectations may result in removal from activities, calls made to parents, or early dismissal for the day or from the remainder of VBS. Parents or guardians must arrange for all transportation at their own expense.

Release and Waiver
*Photo/Press Release* I grant and give consent to the participation in interviews, the taking of photographs, and the use of the first and last name of the above-named child. I also grant newspapers, publications, VBS staff and volunteers, and LWM staff the right to edit, use, and reuse said products for legal non-profit use in print, on the internet, and in other forms of media. I also release any newspapers, publications, VBS staff and volunteers, and LWM staff from all claims, demands, and liabilities whatsoever in connection with the above.

*Health Release* This health history is correct and complete as far as I know. The above-named child has permission to engage in all program activities except as noted on this form. I give permission to Vacation Bible School (VBS) staff and volunteers, and Living Water Ministry (LWM) staff to provide routine health care, administer prescription medications, and seek emergency medical treatment. I agree to the release of any records necessary for insurance purposes. I give permission to VBS staff and volunteers, and LWM staff to arrange necessary medical-related transportation for me or my child if needed.
If I cannot be reached in an emergency, I hereby give permission to the physician selected by VBS staff and volunteers, and LWM staff to secure and administer treatment, including hospitalization. I acknowledge that I will be ultimately responsible for the cost of any medical care should the cost not be reimbursed by my health insurance provider. I understand that this completed form may be photocopied for medical purposes.
I hereby give permission for VBS staff and volunteers, and LWM staff to administer over-the-counter medications as deemed necessary except as noted on this form. I understand and agree to abide by all policies and restrictions placed on me or my child’s participation in camp activities.

*Waiver for Child by Parent/Guardian* As the parent or legal guardian of the above-named child, I release Vacation Bible School (VBS) staff and volunteers, and Living Water Ministry (LWM) staff from and against all losses, claims, actions, costs, expenses and/or damages including attorney fees, arising out of my child’s participation in this program and all its activities.

Parent/Guardian Signature *
By typing your full name below, you are signing this electronic document.
Your answer
Thank You!
After submitting this form, you will be able to register another child and/or make edits until registration closes on July 14 at 11:59pm.
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