FPC-Holt VBS Registration
Suggested donation of $5 may be turned in at the office or in the offering plate (write VBS in the memo line).
Email address *
First Name *
Your answer
Last Name *
Your answer
Grade Entering *
Date of Birth *
Your answer
T-Shirt Size
Parent/Guardian Name *
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Home Phone *
Your answer
Parent/Guardian Cell Phone *
Your answer
Parent/Guardian Email *
Your answer
Emergency Contact Name and Phone *
Your answer
Insurance Company and Policy Number *
Your answer
Allergies, Medical Conditions, Medications *
Your answer
If you are attending with a friend(s), please tell us the name(s): *
Your answer
Release for Medical, Liability and Publicity
Medical & Liability Release – Valid July 24-28, 2016: In the event of sickness or some medical emergency, I request that my child receive any medical attention or treatment deemed necessary, therefore I give permission to any hospital, doctor, and/or health care provider to transport, treat and/or admit my child for care. I understand that I am responsible for all expenses and charges for the treatment and care of my child. In the event that I am not present at the time of the emergency or cannot be contacted, my child’s care has been entrusted to the staff and designated ministry leadership of First Presbyterian Church of Holt.

Publicity Release: I grant to First Presbyterian Church Holt the right to take photographs of me and my family in connection with the above-identified event. I agree that First Presbyterian Church of Holt may use such photographs of me and or my family with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above.

By selecting "yes," I am agreeing to the release statements above. *
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