VBS Registration
Who Is My Neighbor VBS Participant Registration June 4-8, 2017; 5:30-8:15 pm. *Please fill in all information*
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Name of participant:____________________________________
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Participant’s address:______________________________________
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Age:______ Grade completed:_______ T-shirt size_____________
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List all known allergies and conditions:___________________________________________________________________________________________________________________________________
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Parent/Guardian Information:Name of parent/guardian:______________________________
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Parent/guardian address:______________________________________
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Parent/guardian phone number:_________________________________
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Pick- Up Information:
Please list persons, other than parent or guardian, who are authorized for pick-up:____________________________________________________________________________________________________________________________________
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Please list any person who are NOT authorized for pick up:_____________________________________________________________________________
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Emergency contact:
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Contact:_______________________________________
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Telephone number:___________________________________________
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Relationship to participant:________________________________________
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Photo/video release:
In the event that we make photo or video slide show of normal ministry events and functions, I give permission for my child to be included in those photos or videos, which might be placed online.
____Yes my child can be included in them.
____I don’t wish for my child to be included in them.
By signing this form I am hereby giving permission for the above named person to participate in and travel to and from events sponsored by Welti Cumberland Presbyterian Church for the duration of the time listed above. In case of accident or injury, permission is granted for medical treatment to be administered, as needed. I acknowledge that, in the event of injury or accident, our own medical insurance takes priority. In the case that I/we are not adequately insured in the case of injury or accident, I agree personally to assume the risk for our family and ourselves. I also, agree to cover the cost of any damage my child may cause to the facilities they will be using. I also acknowledge that the church is not responsible for the loss of personal property. I agree to come transport my child home if they disqualify themselves from any event. Disqualification may occur if my child commits a major violation such as inappropriate sexual conduct, possession and/or use of tobacco, alcohol, or illegal substances, or unwillingness to follow instructions of the youth leader/chaperon/camp/retreat director in charge. The youth leader/chaperon from Welti CPC will determine if disqualification is necessary. I also agree not to hold Welti Cumberland Presbyterian Church, Hope Presbytery of the Cumberland Presbyterian Church, Southeast Synod of the Cumberland Presbyterian Church, Cumberland Presbyterian denomination, and/or the adult chaperone's responsible for any injury or damages my youth may incur.
Signature of Parent/Guardian: ________________________________________ Date: _______________
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