Grace Reformed Baptist Church VBS REGISTRATION

Child's Last Name *
Your answer
Child's First Name *
Your answer
If your child has a preferred nickname, please list it here:
Your answer
Date of Birth *
(example 7/22/2003)
Your answer
Most Recent Grade Completed *
Street Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Primary Parent/Guardian Name *
Your answer
Primary Parent/Guardian - Main Phone *
(example 815.555.5555)
Your answer
Primary Parent/Guardian - Secondary Phone
Your answer
Emergency Contacts
(please list additional names to contact in the event of an emergency, include a phone number and list the relation to the child)
Your answer
Others that have your permission to pick up your child (individual's name, relation to child and phone number)
Individuals not listed here will NOT be allowed to pick up your child
Your answer
List any specific allergies, dietary needs, or health conditions that your child has
Your answer
Important Note on Dietary Restrictions:
While we do try to accommodate different allergy needs, we cannot make any guarantees. If your child has a serious or life threatening allergy, we ask that you be responsible for his/her snack. Thank you for your understanding.
Is your child allergic to bee stings? *
T-Shirt Size *
Please read the waiver and release and select "yes" if you understand and agree *
I, the undersigned, acknowledge and fully understand that my child will be engaging in activities that might involve the risk of injury which might result not only from his/her own actions, inactions, or negligence, but the action, inaction, or negligence of others or the condition of the premises or any equipment used, and further, that there may be other unknown risks not reasonably foreseeable at this time. I assume all the foregoing risk and accept personal responsibility for the damages following such injury and I agree and relinquish all claims I may have as a result of participation against the volunteers of Grace Reformed Baptist Church and the Vacation Bible School Program from any and all claims from injuries, damages, or losses which I or my child may have or which may accrue to me on account of participation in the program. I further agree to indemnify and hold harmless and defend Grace Reformed Baptist Church and the Vacation Bible School Program and their staff and families from any and all claims resulting to me or my child, arising out of, or connected with, or in any way associated with the activities of the program. In the event of an emergency, I authorize officials of Grace Reformed Baptist Church to secure from any licensed hospital, physician, and/or medical personnel any treatment for any immediate care and agree that I will be responsible for payment of any and all medical services. I further agree to allow Grace Reformed Baptist Church to take pictures and video and agree that Grace Reformed Baptist Church retains the right to use these pictures and video in any way Grace Reformed Baptist Church deems useful, responsible and prudent. I have read and fully understood the above waiver, details, and release of claims and permission to secure necessary medical treatment.
Full name of person completing this form *
Your answer
Email address of person completing this form *
Your answer
How did you find out our VBS?
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