2026 VBS Child Registration

Vacation Bible School will be held at Rumple Memorial Presbyterian Church Monday, June 15 to Thursday, June 18, from 9:00 a.m.- 12:00 p.m. Children who are rising 1st through rising 5th graders are invited to join us!

Please fill out a separate registration form for each child and click submit.

Child's Name

Date of Birth

What grade will your child be in for the 2026-2027 school year?

Age at time of VBS

Parent/Guardian First Name

Parent/Guardian 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

Relationship to child

Are there any concerns or details about your child that we should know, including dietary restrictions?

Person responsible for picking up child from VBS

Names of other people authorized to pick child up from VBS

Their phone number

Relationship to child

I hereby release Rumple Memorial Presbyterian Church and St. Mary of the Hills Episcopal 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 Vacation Bible School.

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 give Rumple Memorial Presbyterian Church and St. Mary of the Hills Episcopal 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.)

Yes No

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

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

Description

Please fill out a separate registration form for each child and click submit.

2026 VBS Child Registration

Description

Please Fix the Following