Van UMC Special Needs VBS 2018
Monday June 25 - Wednesday June 27, 2018
9:00 - 11:30 am
ages: 2 - adult
Van United Methodist Church 326 W Main St Van TX 75790
903.963.5563 vanumc.org
ONLINE REGISTRATION WILL CLOSE FRIDAY, JUNE 22, 2018 at 9pm
Registration At the Door Will Be Possible during Vacation Bible School
Participant First Name *
Your answer
Participant Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Address *
Your answer
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Parent/Guardian Cell Phone *
Your answer
Parent/Guardian Email
Your answer
Participant Basic Information
Allergies or Food Restrictions (please list) *
Your answer
Diagnosis *
Your answer
Medicine *
Your answer
Hygiene Needs/Bathroom Capabilities *
Your answer
Behavioral Support Needs *
Your answer
What Makes Me Uncomfortable *
Your answer
What Makes Me Comfortable *
Your answer
Two Emergency Contacts In Case Parent/Guardian Cannot Be Reached
Emergency Contact 1 First Name *
Your answer
Emergency Contact 1 Last Name *
Your answer
Emergency Contact 1 Phone *
Your answer
Emergency Contact 2 First Name *
Your answer
Emergency Contact 2 Last Name *
Your answer
Emergency Contact 2 Phone Number *
Your answer
Please List Any Additional Helpful Hints (anything that will make my VBS experience enjoyable)
Your answer
Declarations of Consent (All Three Required)
By completing the online registration, I acknowledge that I, the parent/guardian of the above named participant, have the authority to answer the following consents on behalf of the participant:.
Emergency Medical Treatment Consent - Van United Methodist Church Staff and/or Volunteers are granted permission to order hospitalization, treatment, anesthesia, and/or surgery, if necessary, in the case of an emergency when the parent/guardian cannot be reached. *
Required
Waiver of Liability Consent - Van United Methodist Church, Church Staff and/or Volunteers are hereby released from any and all liability for any additional illness and/or injury to the participant, and/or for any accidental damage, destruction, and/or loss of the participant's property during an activity at church. *
Required
Photograph/Image Consent - Van United Methodist Church, Church Staff and/or Volunteers are hereby granted permission to use the participant's photo or image in presentation(s) at the church, church publication, church website, and/or church Facebook page. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms