VBS Registration Form
Bedford Free Methodist Church: June 9th-14th
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Name of Child *
Date of Birth *
MM
/
DD
/
YYYY
Grade Just Completed *
Street Address *
City *
State *
Zip Code *
Names of Parents/Guardians *
Cell Phone #1 *
Cell Phone #2 *
Email Address: *
Emergency Contact Name and Cell Phone *
Allowed Pick Up (Please designate 3 adults, including yourself) *
Allergies/Other Medical Conditions *
Special Considerations/Requests
I understand that pictures taken of my child may be used for promotional purposes. *
Please type your name below to sign for the following: 
As the legal custodial parent or guardian of the student who desires to voluntarily participate in the event listed above (VBS), assume all responsibility for any accidents or other mishaps, including, but not limited to, serious bodily injury, permanent disability, and/or death, with respect to my child, and I hereby waive my right and child's right to any claim, cause of action, and/or right to file a lawsuit, and further release the Bedford Free Methodist Church, Wabash Conference of the Free Methodist Church, the Free Methodist Church of North America, and the directors, officers, sponsors, employees, agents, and volunteers of each entity from any and all responsibility or liability of any nature whatsoever for any loss or damage to my child’s property or person, including personal injury and/ or death sustained on (VBS) described above. This instrument shall be binding upon the relatives, personal representatives, heirs, beneficiaries, next of kin or assigns of the above-named child and shall insure to the benefit of the organizations named as well as their directors, officers, sponsors, employees, agents, volunteers, successors and assigns. I have carefully read this Waiver & Release of Liability & Permission for Treatment and by my signature, I am stating that I understand, and accept all of its provisions, and understand that I am giving away substantial legal rights for both my child and myself and have the appropriate authority to execute this Waiver & Release. I also give permission to the staff of the Bedford Free Methodist Church and its trusted volunteers to order x-rays, routine tests, and treatment for my child if I cannot be reached in an emergency. I further give permission to hospitalize, secure treatment, and order injections, anesthesia, or surgery for my child named above.
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