VBS Registration Form

VBS Registration Form

Please fill out a form for EACH child participating in VBS. After each form submission, scroll up to submit another form. There is a one-time registration fee of $5 per child due on the first day of VBS.
Child's First Name*
Child's Last Name*
Child's Birth Date*

YearMonthDay
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent(s) / Guardian(s) Name*
Your E-mail*
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone*
Does your child have any special needs we need to be aware of? (such as allergies, dietary restrictions, behavioral concerns, etc.)*
At the end of each day of VBS, how can your child be dismissed?*
Would you like to receive information about Kids Clubs or Youth Programming in the future?*
General Release and Waiver

I understand and acknowledge that Boissevain Mennonite Brethren Church will not allow the minor to participate in the Activities without releasing and holding Boissevain Mennonite Brethren Church harmless from any liability arising out of participation in the Activities. I understand there may be risks involved in the minor’s participation in the Activities and fully assume such risks on his or her behalf. I REQUEST THAT BOISSEVAIN MENNONITE BRETHREN CHURCH ALLOW THE MINOR TO PARTICIPATE IN THE ACTIVITIES, AND IN CONSIDERATION THEREOF AGREE HEREBY TO RELEASE AND FOREVER DISCHARGE BOISSEVAIN MENNONITE BRETHREN CHURCH, ITS OFFICERS AND DIRECTORS, AND ITS EMPLOYEES, AGENTS, AND ANY PARTIES VOLUNTEERING ON BEHALF OF THE CHURCH FROM ALL ACTIONS, CAUSES OF ACTION, INJURIES, CLAIMS, DAMAGES, COSTS OR EXPENSES OF ANY KIND GROWING OUT OF OR RELATED TO ANY SUCH ACTIVITIES IN WHICH THE MINOR PARTICIPATES. I UNDERSTAND THAT THIS IS A FULL AND COMPLETE RELEASE OF ALL INJURIES AND DAMAGES WHICH I OR THE MINOR MAY SUSTAIN AS A RESULT OF HIS OR HER PARTICIPATION IN ANY OF THE ACTIVITIES, REGARDLESS OF THE SPECIFIC CAUSE THEREOF. I further acknowledge and agree that I have given my consent for the minor to participate in the Activities and to remain in the custody of the Boissevain Mennonite Brethren Church representatives while participating in the Activities. I further acknowledge and agree that I give consent for the minor to be photographed during VBS activities and I give my consent to allow VBS personnel to publish photographs or video for VBS promotional materials to be used in the Boissevain Recorder or to be reproduced in video/slide show format on DVD without any financial compensation or further consent. This agreement is binding on the minor’s heirs, successors, and personal representatives.
MEDICAL TREATMENT AUTHORIZATION AND POWER OF ATTORNEY

In the event the minor suffers an injury or condition during his or her participation in the Activities, including transportation to and from the Activity, which may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me have been unsuccessful. I hereby appoint eligible members of the Boissevain Mennonite Brethren Church leadership team as my agent(s) to act for me and in my name (in any way I could act in person) to make any and all decisions for the minor concerning his or her personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate when the agent is first able to contact me.
Child's 9 digit MB Health Number*
Alternative Emergency Contact Information

In case we cannot reach you
Emergency Contact Name*
First and Last Name
Phone Number*
Please enter a valid phone number.
Parent / Guardian Signature*

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VBS Registration Form

General Release and Waiver

MEDICAL TREATMENT AUTHORIZATION AND POWER OF ATTORNEY

Alternative Emergency Contact Information