Vacation Bible School; July 8-12, 2019 - First Lutheran Waltham
Registration form for children at Vacation Bible School at First Lutheran Church in Waltham.

Please note this is an application for the First Lutheran VBS. You will receive an email to let you know if we have a space available for your child.

Deadline for applications are May 15, 2019.

For questions or more information, please contact the VBS Directors, Holly or Anne, at 781-893-6563 or email firstlutheranvbs@gmail.com
To Mars and Beyond
Morning or Extended Day Program *
Child First Name *
Your answer
Child Last Name *
Your answer
Nickname *
If different from first name. For name tag
Your answer
Gender *
Your answer
Parent/Guardian Name *
Your answer
Address *
Your answer
Home Telephone *
Your answer
Cell Phone *
Your answer
Preferred email *
Your answer
Child’s Birth date (Must be 3 by 4/1/19) *
MM
/
DD
/
YYYY
School grade completing this spring *
Home congregation (if any) *
Your answer
Person(s) responsible for bringing this child to VBS *
Your answer
Person(s)'s relationship to child
Your answer
Person(s) responsible for picking up this child during VBS *
Your answer
Telephone(s) for Person(s) picking up child (if other than parent) *
Your answer
Person(s)' relationship to child *
Your answer
Please list the name of anyone who may not pick up this child.
Your answer
Special needs/circumstances *
Your answer
If this child is attending extended day, please complete following: *
I, as parent/guardian, give my permission for my child to attend and participate in the walking field trip to the park (as part of the extended day program), during the week of July 8th – 12th.
Emergency Release *
As parent/guardian, I do hereby consent to whatever treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which, in the opinion of the VBS Directors, may endanger his-her life, physical impairment, dental diagnosis or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.
Parent/Guardian *
Your answer
Relationship to minor *
Emergency phone *
What's the first number to call in case of an emergency?
Your answer
Will this child need ANY medication during VBS? *
If yes, please list
If the child requires medication during VBS, please be bring labeled medication in a ziplock bag.
Your answer
Does this child have allergies *
If yes, please list allergies and treatment
Your answer
Insurance Information *
Insurance company and number for child
Your answer
Do you give permission for your child’s picture to be used in advertisements *
(i.e. group photo to local newspaper, in photo display, slide show, closed Facebook group, etc. Child's name will never be listed. Photos will not be used on public websites or public social networking sites)
Would you like to volunteer *
Required
Questions or comments?
Your answer
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