This ZOO is Not For You

This Zoo is Not For You - A VBS Event

at St. Luke's Episcopal Church

8 East Keller St., Mechanicsburg, PA

Saturday, June 13. 9-11AM

We are inviting independent 3-year-olds and older children.

Join us to enjoy a special story with Pastor Kate, music with Grandpa Bob and his Group, crafts, games, snacks and lots of fun!

Please help us by registering online by June 6th.

Thanks so much!

Teens can apply to be aides.

Child/Youth Name

First NameLast Name

Birth Date

Date

Parent/Guardian Information

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Does the child/youth have any allergies, chronic illness, or medical conditions? If yes, please describe and detail treatment for the condition.

Special Concerns? Please detail here...

I give permission to use my child’s image in print and online media without names.

Person authorized to pick up this child other than parent: Name .
Relationship to the child: Relationship .
The safety of all children is extremely important to us! SO photo ID will be required when picking up your child.

Informed Consent and Acknowledgement AUTHORIZATION TO TREAT: I authorize the adult agents and employees of St. Luke’s Episcopal Church in charge of the program to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to my above named minor child under the general special supervision and upon the advice of a physician and surgeon licensed under the provision of the Medical Practice Act, pursuant to Section 25.8 of Pennsylvania Civil Code and agree to be responsible for all cost thereby incurred.
I have read the above application and agreement and fully understand that I assume all risks for any injuries received.

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.

Signature of Parent or Guardian

Date of Electronic Signature

Date