VBS 2024 Child Registration

VBS will be held at St. Mary of Hills Episcopal Church from Monday, June 17th- Thursday, June 20th.

Child's Name

Date of Birth

Grade Completed

Age

Parent's First Name

Parent's Last Name

Address

Primary Phone

Secondary Phone

This address will receive a confirmation email

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Are there any concerns or details about your child that we should know?

Person responsible for picking up child from VBS

Their phone number

Relationship to child

I, hereby give permission for my child to participate with the St. Mary of the Hills Episcopal Church and Rumple Memorial Presbyterian Church Youth and Children’s ministry activities (both on and off the campus) from June 2024-June 2025. This includes transportation in the car of an adult volunteer.

I hereby release St. Mary of the Hills Episcopal Church and Rumple Memorial Presbyterian Church, its staff members and volunteer leaders from any and all liability due to injury, loss, or damage to person or property that may occur during the course of the trip, including travel time in personal vehicles.

In case of a medical emergency with my child and I cannot be reached, I give my permission to the adult leaders to permit hospital personnel and/or a licensed physician to perform emergency treatments and administer medicine in conjunction with such emergency treatment to my above mentioned child.

I have read and understand the above assumption of risk and release. Please type your full name and date.

I give St. Mary of the Hills Episcopal Church and Rumple Memorial Presbyterian Church permission to use photographs and video of my child/youth on their website, social media, and church publications. (No child or youth will ever be identified by name on the web/social media, but see next note)

Yes No

Because of livestreaming and our bulletins being available on our website, do we have permission to use your child/youth’s first and last name in worship and in the bulletin?

Yes No

Medical Information

List any medications your child is currently taking

Are there any current medical conditions or medical history that we should be aware of?

List any allergies that your child has

Health Insurance Company

Health Insurance Policy Number

VBS 2024 Child Registration

Description

Please Fix the Following