FMBC Vacation Bible School Registration Form

Vacation Bible School Registration

This form accommodates the entry of six children. If there are more, please complete an additional form.
Parent/Guardian Information
Primary Parent/Guardian*

First NameLast Name
Email*
Cell Number*
Will you be attending the Adult VBS Class?

YesNo
Alternate Parent/Guardian

First NameLast Name
Email
Cell Number
Will this person be attending the Adult VBS Class?

YesNo
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number

Emergency Contact Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Child/Participant(s) Information
Participant #1 Name*

First NameLast Name
Age*
Gender*

MaleFemale
VBS Grade (upcoming school year)*
Enter another Child/Participant?

No. Take me to Medical Information.Yes

Participant #2 Name

First NameLast Name
Age
Gender

MaleFemale
VBS Grade (upcoming school year)
Enter another Child/Participant?

No. Take me to Medical Information.Yes

Participant #3 Name

First NameLast Name
Age
Gender

MaleFemale
VBS Grade (upcoming school year)
Enter another Child/Participant?

No. Take me to Medical Information.Yes

Participant #4 Name

First NameLast Name
Age
Gender

MaleFemale
VBS Grade (upcoming school year)
Enter another Child/Participant?

No. Take me to Medical Information.Yes

Participant #5 Name

First NameLast Name
Age
Gender

MaleFemale
VBS Grade (upcoming school year)
Enter another Child/Participant?

No. Take me to Medical Information.Yes

Participant #6 Name

First NameLast Name
Age
Gender

MaleFemale
VBS Grade (upcoming school year)

Medical Information
Do any of the registered participants have any allergies, chronic illness, or medical conditions? If yes, please describe for each participant. If no, type in NONE.*
Are any of the registered participants prescribed an inhaler? If yes, please explain any instructions for each participant. If no, type NONE.*

Medical Release and Waivers
Participation Agreement and Acknowledgement

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant's parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above (the "activity"), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the "activity sponsor"). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.
Permission To Photograph

During the course of this year’s Vacation Bible School, Faith Missionary Baptist Church (FMBC) volunteers will be taking photographs and making videos of the children herein registered in their classroom and activity settings. These photographs and videos will only be used for promotional purposes for the ministries of FMBC through its online website and social media platforms. FMBC will not provide any photographs or videos made to any third party nor publish the children’s names or other personal information with any such photographs or videos. By signing this Participation Agreement, I warrant that I am the legal parent or guardian of the registered children and accordingly, hereby grant permission to FMBC to include the image of any of said children to be included in any photographs or videos made as described above unless the button below, denying such permission, is filled.
Permission GRANTEDPermission is NOT GRANTED
Medical Release and Authorization

As Parent and/or Guardian of the named child participant(s), 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 athlete. 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 Faith Missionary Baptist Church and its affiliates including Officers, Trustees, Teachers, and Volunteer Helpers 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 season.

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.
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.
Date*

MonthDayYear
Date
Signature*

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Vacation Bible School Registration

Child/Participant(s) Information

Medical Information

Medical Release and Waivers

Permission To Photograph