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).
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Email *
First Name of Child *
Last Name of Child *
Grade Just Completed *
Date of Birth *
T-Shirt Size
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Parent/Guardian Name *
Street Address *
City, State, Zip *
Home Phone *
Parent/Guardian Cell Phone *
Parent/Guardian Email *
Emergency Contact Name and Phone *
Insurance Company and Policy Number *
Allergies, Medical Conditions, Medications *
If you are attending with a friend(s), please tell us the name(s): *
Release for Medical, Liability and Publicity
Medical & Liability Release – Valid July 26-29, 2020: 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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