Kishwaukee VBS
Kishwaukee Communitty EPC presents 2019 Vacation Bible School : In the Wild
June 24-28 9:00-11:30 am
Ages 4 years old (by June 24) to 5th grade
Family Last Name *
(use child's last name)
Your answer
Parent's Name *
Your answer
Contact Information
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Email Address *
Used only to receive VBS information
Your answer
Phone Number *
Example 815-123-4567
Your answer
Emergency Contact (Full Name) *
Your answer
relation to family *
Your answer
Emergency Contact Phone Number *
Your answer
VBS Sunday
Do you plan to attend VBS Sunday Worship Service on June 30th at 10:00am *
Do you have a home church *
Child(ren) to be enrolled
Select age 4 & 5 by 6/24/19 or select the grade recently completed.
First Child's Name (ex: John Smith) *
Your answer
First Child's Grade *
Second Child's Name (ex: John Smith)
Your answer
Second Child's Grade
Third Child's Name (ex: John Smith)
Your answer
Third Child's Grade
Fourth Child's Name (ex: John Smith)
Your answer
Fourth Child's Grade
Medical Information
Allergy Alerts & Medical Conditions *
List Child's Name and allergy, medical, or other pertinent information. State NA (Not applicable) if there are no allergy or medical conditions to note.
Your answer
Physician's Name *
Your answer
Preferred Hospital *
Your answer
People who may pick up your child(ren) *
Your answer
VBS 2019 Waiver
I allow the undersigned to the following: *
List all children attending
Your answer
May we have permission to photograph your child? *
May we have permission to use your child's/children's photo for the purpose of promotion? *
Pictures may appear on the Kishwaukee EPC Website or church related brochures/newsletters.
If you and the physician specified above cannot be reached in an emergency, and in the judgment of church leaders immediate and/or hospital attention is indicated, do you authorize responsible church leaders to send your child, properly accompanied, to an available hospital or physician? *
PARENTAL AGREEMENT: We, the parents (legal guardians), of the child (children) registered above, do hereby consent to our child (children) participating in the Vacation Bible School program offered at Kishwaukee Evangelical Presbyterian Church from June 24-28, 2019. We assume all risks and hazards incidental to such participation and do hereby release, waive, absolve, indemnify, and agree to hold harmless Kishwaukee Evangelical Presbyterian Church, their leaders, volunteers, and any persons supervising or assisting or in any way connected to VBS or any claim arising out of or injury to our child (children) as a result of participating in VBS. *
I understand that my typed signature serves as my written signature.
Your answer
Date *
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