Mentor UMC Summer 2017 Registration
Vacation Bible School-June 19-23 9 am to 12 pm ($20 per kid: Cash or Check:
$20; Visa, MC, Discover, Diners Club, ACH: $21; American Express: $21.15)

CASH or CHECK Payments mailed/given Tammy Palermo, Mentor UMC, 8600 Mentor Ave., Mentor, OH 44060
ONLINE Payments as indicated at www.mentorumc.org/summer-programs

Registration is for (check all that apply):
Required
Child’s Last Name
Your answer
Child’s First Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Home Phone Number
Your answer
2016-17 Grade in School (the grade JUST completed)
Parent's First Name
Your answer
Parent's Last Name
Your answer
Parent's Email Address
Your answer
Home Address
Your answer
Parent's Cell Phone Number
Your answer
Emergency Contact's First Name (NOT parent already listed)
Your answer
Emergency Contact's Last Name (NOT parent already listed)
Your answer
Emergency Contact's Cell Phone (NOT parent already listed)
Your answer
Any allergies, dietary restrictions, learning concerns, developmental concerns, or other things you would like to share
If you answered "Yes" above, please elaborate. This information will only be shared as needed.
Your answer
Person responsible for pick up
Your answer
Pick up person phone number
Your answer
Pick up person's relationship to child
Your answer
Do you agree to allow photos/videos of your child to be used in church presentation or church promotional materials?
Required
Do you agree to allow photos of your child to be used online?
Required
Do you agree to allow video of your child to be used online?
Required
How did you hear about Mentor UMC Summer Programs?
Your answer
Emergency Waiver~ In the event that reasonable efforts to contact me have been unsuccessful, I hereby give my consent for emergency medical treatment by a certified first aid giver. In the event that additional treatment is needed, the staff of the Emergency Department of the hospital listed below or the closest one to the event location, has my permission to treat my child.
Required
Preferred Hospital
Your answer
Typing your name here constitutes an electronic signature.
Your answer
I understand fees still need to be paid to Mentor UMC unless I have requested a scholarship by emailing tpalermo@mentorumc.org.
Required
I will be paying by
Required
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