VBS Participant Registration
First name of child *
Your answer
Last name of child *
Your answer
Parent(s) Name (First and Last) *
Your answer
Gender *
Birthdate (MM/DD/YEAR) *
MM
/
DD
/
YYYY
Grade Entering Fall 2017 (Preschool is FULL, please contact Wendy Hicks 739-1183 to be placed on the waiting list.) *
Required
Street Address *
Your answer
Zip Code *
Your answer
Contact Phone Number(s) *
Your answer
Parent/Guardian Email *
Your answer
Any Allergy or Medical Information that we need to know
Your answer
Emergency Contact Name and Number *
Your answer
LIABILITY RELEASE Every activity sponsored by SCPC is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By agreeing to this question, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree to hold SCPC, or its employees or volunteer assistants harmless for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are agreeing for the minor listed on this form and the signature is for both a medical and liability release. Our church’s insurance is excess insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is participating in a church-related activity. In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary. *
Required
Names of any one else allowed to pick up your child:
Your answer
If you regularly attend church, which one? If not, please list none. *
Your answer
How did you hear about our VBS? *
Your answer
MEDIA CONSENT I give my consent and permission for the taking of photographs and/or video of my child during 2017 VBS and waive and/or assign any and all rights (including copyright) in such media to SCPC for promotional use in print and online. SCPC will not use their full names with the picture of the students on their website, nor will it tag any children used on SCPC or Kids at the Creek facebook pages. *
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