Child Registration Form KMC VBS 2018
VBS Dates/Times: June 7-8th (Thurs/Fri) 6pm-8:20pm; June 9-10th (Sat/Sun) 10:30am-1:30pm

$20 Fee Per Child; scholarship available
Registration due by: May 27th
$5 late fee Registration after May 27th

**Register online now and if you do not attend KMC, you can pay later when you check in your child the first day of VBS

Child's First Name *
Your answer
Child's Last Name *
Your answer
Gender *
Child's Age *
Child's Date of Birth *
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School Grade Completed in May 2018 *
My Child Will Attend VBS (check all that apply): *
Required
Parent's First Name *
Your answer
Parent's Last Name *
Your answer
Parent's Phone# *
Use Format XXX-XXX-XXXX
Your answer
Parent's Email *
**We will be sending daily e-newsletters and important announcements throughout VBS.
Your answer
Name of Home Church (if any) *
Your answer
Allergies or Other Medical Conditions (if any)
Your answer
Emergency Contact (First and Last Name) *
Your answer
Emergency Contact (Phone Number) *
Use Format XXX-XXX-XXXX
Your answer
Emergency Contact (Relationship to Child) *
Your answer
I hereby (grant / do not grant) permission for Kansas Mission Church to use pictures of my child on their website for informational or promotional purposes. Please choose one. *
Medical and Legal Disclaimer
I authorize, by signing below, Kansas Mission Church (hereafter “KMC”) and its agents to manage any medical treatment that my child may need in an event of emergency while attending this event. As a parent, I am liable and agree to pay all costs and expenses incurred in connection with any medical services that my child may receive, and I waive all rights to file a suit or a legal complaint against KMC or its agents for any liability, accident or injury sustained by my child during this event.

I verify that all statements are true and correct on this form. I understand that there are inherent risks involved in this activity and I release Kansas Mission Church of any and all liability.

Parent / Legal Guardian Name: *
Your answer
Date of Signature: *
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