VBS Online Registration Form

Online Registration

Please note:

Seperate registration forms must be filled out for each child participating in Vacation Bible School.

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

T-shirt size

Grade Completed and Age

A light supper will be served at 5:30pm. Will you attend? For no, put zero, or put the number of people that will join us for supper.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Please list all persons authorized to pick up your child and their relationship to the child. (John Doe-neighbor). In the event it is not a parent, please note a valid I.D. will be required at sign out.

Alt. Phone Number

Area CodePhone Number

Do we have permission to use sunscreen if needed on your child?

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Roanoke Seventh Day Adventist Church during the selected Vacation Bible School period. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless {Roanoke Seventh Day Adventist Church} . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising during the VBS sessions.

In case of injury to said child, I hereby waive all claims against {Roanoke Seventh Day Adventist Church} . including all leaders and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities.

I understand that photos may be take of my child/children during VBS. hereby grant permission to Roanoke Seventh Day Adventist Church representatives, to take and use: photographs and/or digital images of me for use in news releases and/or educational materials. These materials might include printed or electronic publications, Web sites or other electronic communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of Roanoke Seventh Day Adventist Church.

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the (Roanoke Seventh Day Adventist Church) and its affiliates including leaders, teachers, to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered VBS.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

E-mail

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Roanoke SDA Church Vacation Bible School July 17 - 21, 2022