Vacation Bible Camp Registration
Welcome to Mars and Beyond!
We are excited this year to offer a full day Vacation Bible Camp experience for your child!
Ages: 4-10
Dates: August 12-16, 2019
Times: 8:30am - 5:00pm
Fee: $100 per child
Fees can be dropped off at the church office at 1111 Dakota Street. Please make cheques payable to The United Church in Meadowood.
Spaces are limited. Payment of fees will reserve space on a first come first serve basis.

Morning Snack is included in the cost, children will need to bring their own nut free lunch and afternoon snack.

Questions? Contact Chelsea and Olivia at vbc.ucim@gmail.com or Stacey at ce@ucim.org
General Information
Information received is confidential and is being gathered for the purposes of serving your child while in the care of The United Church in Meadowood. Any medical information collected here serves to authorize The United Church in Meadowood, and its staff and volunteers, to obtain medical assistance in case of emergency.
Child's Name *
Your answer
Date of Birth: *
MM
/
DD
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YYYY
Last School Grade Completed: *
Your answer
Address: *
Your answer
Phone Number: *
Your answer
Secondary Contact Number:
Your answer
Email Address: *
Your answer
Manitoba Health Card #: *
Your answer
Family Doctor: *
Your answer
Allergies:
Your answer
Emergency Contact (name and phone number): *
Your answer
Dismissal Information, name of person(s) who may pick your child up from VBC: *
Your answer
Does your child have any physical, emotional, mental, behavioural concerns or limitations staff should be aware of? *
Required
If yes, please explain:
Your answer
Is your child bringing any medications with him/her? *
Required
If yes, please list:
Your answer
Home Church:
Your answer
Please read and indicate your consent by adding your name below:
The safety of your child is our primary concern. Precautions will be taken for their well-being and protection.

I/we, the Parents or guardians named below, authorize Stacey Milne-Ciecko, Candace Maxymowich or one of The United Church in Meadowood Vacation Bible Camp personnel to sign a consent for emergency medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

I/we, named below, undertake and agree to indemnify and hold harmless Vacation Bible Camp Personnel, the United Church in Meadowood, and its Leaders from and against any loss, damage or injury suffered by the participant as a result of being a part of the activities of the Vacation Bible Camp, as well as of any emergency medical treatment authorized by the supervising individuals representing the United Church in Meadowood. This consent and authorization is effective only when participating in events sponsored by the United Church in Meadowood.
Name:
Your answer
Please check below to grant permission for the reasonable use of pictures containing your child in any of the following ways: *
Required
Purposes and Extent
The United Church in Meadowood is collecting and retaining this personal information for the purpose of enrolling your child in our Vacation Bible Camp program, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our organization. This information will be maintained indefinitely as it is a requirement of our insurance company and our Vulnerable Persons Protection policies. If you wish the United Church in Meadowood to limit the information collected, or to view your Child's information, please contact us at 204-256-7002
I have read, understood and agree with the above. Name: *
Your answer
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