Vineyard Presbyterian Church VBS 2019 Registration Form
The Story of Daniel
"Praise be to the name of God for ever and ever: wisdom and power are His. He changes times and seasons; He deposes kings and raises up others." - Daniel 2: 20-21
o Location: Vineyard Presbyterian Church
300 E Belden Ave, Elmhurst, IL 60126
o Date: Thursday, June 27, 2019 - Saturday, June 29, 2019
o Time: 10 am to 3 pm
*Walk-in Registration begins Thursday, June 27th at 9:30 am

o Fee: $30 for the first child; $25 for the second child/sibling; $20 for third and $20 for each child/sibling after
o Free for any child 2 years old and under but please sign them up for a free T-shirt
o Any child, under the age of 3, must have a parent/guardian with him/her at all times

Child Information
Please enter the following information of the child, who will attend the VBS
First Name *
Your answer
Last Name *
Your answer
Age *
Grade in Upcoming 2019-20 *
Gender *
T-Shirt Size *
Allergies: Food and Medicinal: Please write N/A if it doesn't apply to your child *
Your answer
Medical Conditions: Please write N/A if it doesn't apply to your child *
Your answer
Day in Attendance *
Required
Additional Child/Sibling Information
Please enter any additional child(ren) who will attend the VBS

*IF YOU HAVE NO OTHER CHILD(REN) TO REGISTER, PLEASE SKIP TO "PARENT INFORMATION."

Child 2: First Name
Your answer
Age
Grade in Upcoming 2019-20
Gender
T-Shirt Size
Allergies: Food and Medicinal: Please write N/A if it doesn't apply to your child
Your answer
Medical Conditions: Please write N/A if it doesn't apply to your child
Your answer
Day in Attendance
Child 3: First Name
Your answer
Age
Grade in Upcoming 2019-20
Gender
T-Shirt Size
Allergies: Food and Medicinal: Please write N/A if it doesn't apply to your child
Your answer
Medical Conditions: Please write N/A if it doesn't apply to your child
Your answer
Day in Attendance
Child 4: First Name
Your answer
Age
Grade in Upcoming 2019-20
Gender
T-Shirt Size
Allergies: Food and Medicinal: Please write N/A if it doesn't apply to your child
Your answer
Medical Conditions: Please write N/A if it doesn't apply to your child
Your answer
Day in Attendance
Parent/Guardian Information
Please enter the following information.
*We do not share this information with third party resource.
Parent/Guardian Full Name *
Your answer
Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number
Your answer
Email Address *
Your answer
How did you hear about our VBS? *
Required
Emergency Contact
Please give 2 or more contacts in case of emergency.
Name and Phone Number for Emergency Contact #1 *
Your answer
Name and Phone Number for Emergency Contact #2 *
Your answer
Additional Adults, who may pick up the child(ren) after VBS is over
*Please note, we will ask for PHOTO ID for verification.
Name and Relationshop *
Your answer
Waiver and Release Form for Vineyard Presbyterian Church VBS Liability Release and Parental Consent Form
I, as the parent/guardian listed above, give consent for my child(ren), listed above, to participate in the above activities, and I execute the above liability release on their behalf. In consideration of the acceptance of my application for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me or my child(ren) as a result of participation in said event. This release is intended to discharge in advance Vineyard Presbyterian Church, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees. *
Required
Consent for Treatment
I, hereby, give my consent to have the above applicant(s) treated by VPC staff/volunteer member, emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that Vineyard Presbyterian Church will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions. *
Required
Waiver and Release Form for VBS Photo Release Form for Minor Children
I, hereby, authorize Vineyard Presbyterian Church to publish the photographs taken of me and/or the undersigned minor children, and our names, for use in the Vineyard Presbyterian Church website and social media platforms for display in the facility. I release Vineyard Presbyterian Church from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children listed below and that I have the authority to authorize Vineyard Presbyterian Church to use their photographs and names. I acknowledge that since participation in publications and websites produced by Vineyard Presbyterian Church is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by Vineyard Presbyterian Church confers no rights of ownership whatsoever. I release Vineyard Presbyterian Church, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children. *
Required
Special Offering/Donation for Mission
Please note that this donation is entirely voluntary and will take place during the worship service on Saturday, June 29, 2019. 100% of your donations during the worship service will go toward supporting the VBS program for VPC’s sister church in Temax of the Yucatan providence in Mexico, which takes place in the first week of August. We will also send a team to assist and support the VBS program in Temax, Yucatan, Mexico *
Required
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