Passport to Peru - VBS Registration
Event Timing: June 26 - June 30
Event Address: 1282 Chenango Street, Binghamton, NY 13901
Contact us at: (607) 724-0842 or bingnaz@binghamtonwireless.com
Please fill out a new registration form for each child in your family.
Child's Name:
Your answer
Parent/Guardian Full Name:
Your answer
Alternate Pick up (person authorized by parent to pick up child):
Your answer
Address:
Your answer
Home Phone (XXX-XXX-XXX):
Your answer
Cell Phone (XXX-XXX-XXX):
Your answer
Email
Your answer
Emergency Contact 1 (Name, Phone, Relation to child):
Your answer
Emergency Contact 2 (Name, Phone, Relation to child):
Your answer
Child's Date of Birth (XX/XX/XXXX)
Your answer
Allergies:
Your answer
What grade will child be entering?
Would your child like to be placed with a friend?
Your answer
Home Church (If you attend a church regularly):
Your answer
I give permission for any photos taken of my children during Passport to Peru to be used on church websites.
I give permission to my child to participate in Passport to Peru VBS and release Binghamton Nazarene, St. Francis of Assisi, Ogden Methodist, Port Dickinson Baptist, and Chenango Bridge Methodist, its officers, employees, and agents from any liability whatsoever from the above churches, its officers, employees, and agents from any liability or loss they might sustain by reason thereof. In the event I cannot be reached in an emergency, I hereby give permission to any injury or death to person or loss/damage to property sustained by the undersigned for any member of their family, in attendance and the undersigned agrees to defend and indemnify the physician selected by the director of children's ministry to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child named here. Type your name below to agree to the release statement.
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Greene Central School District. Report Abuse - Terms of Service - Additional Terms