Beulah Community Church VBS Registration
June 5-9, 2023
Child Name
First Name
Last Name
Age
Gender
Date of Birth
-
Month
-
Day
Year
Date
Grade level in next school year
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Does the child have any allergies? If yes, please list them below:
Does the child currently taking medications that need to be administered by VBS staff? If yes, please list them below and provide the reason and time to administer:
Does the participant have any medical condition that we should be aware of? If yes, please explain below:
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Parent / Guardian Information
Name
First Name
Last Name
Relationship to Child
Telephone Number
Please enter a valid phone number.
Email
example@example.com
Emergency contact name (if different than above)
Phone Number
Please enter a valid phone number.
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Are you planning to attend the program on Friday night?
Yes
No
What is the best way for your family to receive a copy of the music?
CD
Digital download
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Terms and Conditions
I allow my child to participate in this program.
I hereby authorize the church and volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.
I release the organizers from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Do you allow the organizers to take photos or videos during the activities of your child for advertising and marketing purposes that will be posted on social media?
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Home Church
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