VBS Registration~Stevens Hill Community
3131 Turnpike Road
Elizabethtown, PA 17022
717-367-7299
Questions? absouthard@aol.com
Email address *
Name of Parent(s) *
Your answer
First & Last Name of Child & Age *
Your answer
First & Last Name of Child & Age
Your answer
First & Last Name of Child & Age
Your answer
First & Last Name of Child & Age
Your answer
Address: *
Your answer
Cell Phone: *
Your answer
Alternate 1 Emergency Contact (Name & Cell Phone) *
Your answer
Alternate 2 Emergency Contact (Name & Cell Phone)
Your answer
List Names of other persons authorized to pick up your child/children in your absence:
Your answer
Please list any allergies, medical conditions, or medications of which the leaders should be made aware: (If none, please indicate) *
Your answer
I authorize the leader(s) in charge of the above-mentioned group where it is impractical to communicate with me, to arrange for my child to receive such medical or surgical treatment as is deemed necessary at any time during the activities of the Stevens Hill Community Church or the Brethren. *
Required
I give permission for my child to be photographed. I understand that the images may be displayed in the church publications, church buildings or website. I understand that as a precaution my child's name will not be published or linked with photographs. *
Required
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