VBS Registration Form (2018) - Highland Baptist Church
DATE: July 9-13, 2018 | TIME: 5:30-8:30 PM

ADDRESS:
1 East Highland Road
Parkesburg, PA 19365

EMAIL ADDRESS: info@highland-bc.org
OFFICE PHONE: (610) 857-1670

Child's Name: *
Your answer
Child's Age: *
Your answer
Child's Completed Grade: *
Your answer
Parent's (or Legal Guardian's) Name: *
Your answer
Parent's Email Address: *
Your answer
Parent's Mobile Phone Number: *
Your answer
Emergency Contact's Name: *
Your answer
Emergency Contact's Phone Number: *
Your answer
Home Address: *
Your answer
City | State | Zip Code: *
Your answer
What church do you attend? (Optional)
Your answer
Medical conditions, allergies or physical limitations we should be informed about (Optional):
Your answer
Write any additional information here (Optional):
Your answer
I give my permission for basic first aid if necessary. I understand that I will be contacted if any further treatment is required. *
Required
I give my permission for the church office to publish photos containing my child on the church website / Facebook page. (Child's name will not be identified in pictures.) *
Required
MEDICAL RELEASE AND LIABILITY STATEMENT
"My son/daughter listed above has permission to engage in all activities at Highland Baptist Church from July 9, 2018, until July 13, 2018. In an emergency, if I cannot be reached, I give permission to the Health Officer to secure proper treatment for my child. I, the parent or guardian of the above named individual, acknowledge that participation in indoor/outdoor events necessarily involves risks of physical injury. In consideration for accepting registration of the above named individual, I permit voluntary participation in the Church's program(s). I hereby release, discharge, and hold harmless Highland Baptist Church, its Pastors, Board of Deacons, Staff Employees, and other Volunteers of the Church from any claims arising out of or relating to any physical injury that may result to said individual while participating in the program(s) on its premise(s)."
I agree to the terms and conditions of the Medical Release and Liability Statement of Highland Baptist Church. *
Required
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