SPLASH Program Registration Form 2017-2018
SPLASH is a Christ-centered youth ministry of Hebron Lutheran Church for children K-5th Grade for sharing fun, learning and spiritual growth together, like a weekly mini-Vacation Bible School. SPLASH meets at Hebron Lutheran Church, 3140 Limaburg Road, Hebron, Wednesday night 5:30 - 7:30 p.m. during the school year unless Boone County Schools are closed or other special circumstances necessitate. At SPLASH we SHARE A SIMPLE SUPPER, LEARN MORE ABOUT GOD, SING, PLAY, HAVE FUN AND FELLOWSHIP WITH ONE ANOTHER! SPLASH starts on Wednesday, September 20th. PLEASE FILL OUT ONE REGISTRATION FORM FOR EVERY CHILD coming to SPLASH and bring it with you to SPLASH OR register online by going to Hebron Lutheran’s website (www.hebronlutheran.org) and clicking on the SPLASH registration icon OR call the Church at 859-689-7590. Please have all children attending SPLASH leave any personal items (such as electronics, backpacks, fidget spinners, roller skates, stuffed animals, etc.) at home! They won’t need them!
First Name
Your answer
Last Name
Your answer
Family Role
Please select your role in your family
Email Address
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Emergency Contact 1
List an Emergency contact - Name and Phone Number
Your answer
Emergency Contact 2
List an Emergency contact - Name and Phone Number
Your answer
Special Needs
List any health problems, allergies, dietary restrictions or special needs for this individual. If there are none, please type n/a.
Your answer
Family Doctor Name
Your answer
Family Doctor Phone
Your answer
Other Considerations
Please tell us about any other way Hebron Lutheran Church can help you have a great SPLASH experience
Your answer
IF THIS FORM IS FOR A YOUTH OR CHILD, PLEASE PROVIDE THE FOLLOWING
Age
Your answer
Birth Date
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YYYY
Grade
Your answer
School
Your answer
Parent or Guardian Name
Your answer
Parent or Guardian Email Address
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Work Phone
Your answer
From time to time, we like to take pictures or video for SPLASH and other special events at Hebron Lutheran Church. Although we never use these photos or videos for monetary gain, we occasionally like to include them in the Newsletter or on our Church’s Facebook page or website. By registering your child or dependent for SPLASH and signing this form, you are agreeing to allow your child or dependent to be photographed or video recorded UNLESS you opt out below. If you have questions about this policy, please contact Pastor Andrew or the Church Office.
AUTHORIZATION FOR TREATMENT OF A MINOR
My youth/child, named above, has my permission to attend the SPLASH program at Hebron Lutheran Church. In the event of illness or accident, if the parent or guardian cannot be reached, I authorize the Church, or its agent, to consent to any diagnosis, examination, treatment or hospital care for my child/youth which is deemed advisable by and is rendered under the supervision of a physician. I release the Church and its agents from responsibility in the case of an accident or illness in connection with and authorized Church activities.
Parent/Guardian Signature
By entering your full name in this blank, you agree to the Authorization above.
Your answer
Date
Please give the date today
MM
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DD
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YYYY
Volunteer?
Please check this box if you are interested in volunteering with the SPLASH Program. We will contact you!
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