Black Forest Community Church, UCC Vacation Bible School Registration Form
VBS Dates: June 10-14, 2019, 9:00am-12:00pm
Address: 6845 Shoup Rd, Colorado Springs, CO 80908
Contact us at (719) 495-2207 or office@blackforestcommunitychurch.org
Website: www.blackforestcommunitychurch.org
Miriam & The Magic Tambourine
Be Brave! Trust God! Do Good!
1. Enrollment Information
Please note: This Registration Form has multiple sections. Please complete all 4 sections.
Parents/Guardian Name *
Your answer
Address/City/State/Zip *
Your answer
Phone Numbers: Home/Cell/Work *
Your answer
Email *
Your answer
NOTE: For each child in preschool-kindergarten age group, please bring an extra change of clothes (including underwear) for accidents.
1st Child's Name/Age/Grade Just Completed *
Your answer
2nd Child's Name/Age/Grade Just Completed
Your answer
3rd Child's Name/Age/Grade Just Completed
Your answer
4th Child's Name/Age/Grade Just Completed
Your answer
2. Emergency Contacts and Pickup Authorization
NOTE: The person who picks up the named child/ren must come into the Church Sanctuary to pick up their child/ren from their Leader. ALL child/ren must be signed out by an "Authorized Pickup Person or Emergency Contact".
Emergency Contact #1 (Name/Relationship/Address/Phone #) *
Your answer
Emergency Contact #2 (Name/Relationship/Address/Phone #) *
Your answer
Person(s) Authorized to Pick up Child: (Name/Relationship/Address/Phone #) *
Your answer
Dietary restrictions *
3. Health Information
Please list the name of child when answering the questions
Any Activity Restrictions: *
Your answer
Any Health-Related Information (Allergies or Medical) the VBS Staff Should Know: *
Your answer
Any Other Considerations: *
Your answer
I understand that I will have to pay $10 upon arrival per child (max $20/per family) *
Required
4. Vacation Bible School Release and Consent
Note: Please Initial and Date all 3 below
Consent to Treatment: My child/ren has/have permission to participate in VBS at Black Forest Community Church from 9:00am-12:00pm June 10-14. During this time I can be reached at the phone number listed above. If I cannot be reached in event of an emergency, the people listed above will be available and authorized to act on my behalf. Further, I authorize all medical, surgical, diagnostic, and hospital care or procedures which may be performed prescribed for my child by a licensed physician or hospital when efforts to contact me are unsuccessful and when deemed immediately necessary or advisable by a physician to safeguard my child's health. I waive my right of informed consent to such treatment. **Please type your NAME and DATE below** *
Your answer
Release of Liability: I, on behalf of myself and/or my child/ren, understand that there are inherent risks involved in any program, activity or athletic event, and I release and waive any claim of liability against Black Forest Community Church, it's pastors, employees, agents and volunteer workers with respect to any injury, illness, damage or death to me or my child while he/she participates in the programs and activities of the church. Please note the Black Forest Community Church cannot be responsible for damage to vehicles in the parking lot. **Please type your NAME and DATE below** *
Your answer
Photo Permission: I give my consent for photographs to be taken of my child/ren during events sponsored by the Black Forest Community Church to be reproduced and used for various purposes. Please select Y or N on how we may use the photos. *
Required
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