OUT OF THIS WORLD Registration

Harvest Church is excited to announce "DIVE-IN" for VBS 2023! This week of fun is August 7th-11th from 9am - Noon at Harvest Church. This adventure is FREE and for children Pre-K through 5th Grade. Children exiting 5th grade are welcome to attend and all Pre-K children must be able to toilet themselves independent of any adult assistance due to liabilities and regulations.

DIVE-IN Registration

Please complete the registration questions in this form to register your family for DIVE-IN VBS 2023
Parent/Guardian Information
Your Name*

First NameLast Name
Relationship to Child*
Your Preferred Email*
Cell Phone Number (or other way to contact with event updates or emergencies)*

Area CodePhone Number
Additional Phone Number (optional)

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is there another adult who will be responsible for the care of your child during our VBS week?
Additional Parent/Caretaker*

First NameLast Name
Relationship to Child*
Parent/Caretaker Email (optional)
example@example.com
Cell Phone Number (or other way to contact with event updates or emergencies)*

Area CodePhone Number
Additional Phone Number (optional)

Area CodePhone Number

Is there another adult whose contact information you should provide for this registration?*
Additional Parent/Caretaker*

First NameLast Name
Relationship to Child*
Parent/Caretaker Email (optional)
example@example.com
Cell Phone Number (or other way to contact with event updates or emergencies)*

Area CodePhone Number
Additional Phone Number (optional)

Area CodePhone Number

Child Information

You will be provided with additional space to register each child you plan to attend.
Child Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Birthdate
Grade Entering This Fall*
Gender*
Does this child have any dietary restrictions?*
Please list the dietary requirements or requests for this child.*
Is there any medical information that we should know about for this child?*
Please provide the medical information we need for this child.*
Do you have another child you would like to register at this time?*

Child #2 Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Birthdate Child #2
Grade Entering This Fall*
Child #2
Gender*
Child #2
Does this child have any dietary restrictions?*
Child #2
Please list the dietary requirements or requests for this child.*
Child #2
Is there any medical information that we should know about for this child?*
Child #2
Please provide the medical information we need for this child.*
Child #2
Do you have a third child you would like to register at this time?*

Child #3 Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Birthdate Child #3
Grade Entering This Fall*
Child #3
Gender*
Child #3
Does this child have any dietary restrictions?*
Child #3
Please list the dietary requirements or requests for this child.*
Child #3
Is there any medical information that we should know about for this child?*
Child #3
Please provide the medical information we need for this child.*
Child #3
Do you have a fourth child you would like to register at this time?*

Child #4 Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Birthdate Child #4
Grade Entering This Fall*
Child #4
Gender*
Child #4
Does this child have any dietary restrictions?*
Child #4
Please list the dietary requirements or requests for this child.*
Child #4
Is there any medical information that we should know about for this child?*
Child #4
Please provide the medical information we need for this child.*
Child #4
Do you have a fifth child you would like to register at this time?*

Child #5 Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Birthdate Child #5
Grade Entering This Fall*
Child #5
Gender*
Child #5
Does this child have any dietary restrictions?*
Child #5
Please list the dietary requirements or requests for this child.*
Child #5
Is there any medical information that we should know about for this child?*
Child #5
Please provide the medical information we need for this child.*
Child #5
Do you have a sixth child you would like to register at this time?*

Child #6 Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Birthdate Child #6
Grade Entering This Fall*
Child #6
Gender*
Child #6
Does this child have any dietary restrictions?*
Child #6
Please list the dietary requirements or requests for this child.*
Child #6
Is there any medical information that we should know about for this child?*
Child #6
Please provide the medical information we need for this child.*
Child #6

Emergency Contact Information

Please provide information we can use in case of emergency when parents/caretakers are unable to be reached.
Emergency Contact Full Name*

First NameLast Name
Preferred Phone Number*

Area CodePhone Number
Alternate Phone Number (optional)

Area CodePhone Number
Would you like to provide information for another Emergency Contact?*
Emergency Contact #2 Full Name*

First NameLast Name
Preferred Phone Number Emergency Contact #2*

Area CodePhone Number
Alternate Phone Number Emergency Contact #2 (optional)

Area CodePhone Number

Final Questions
Are there any days in our VBS week where we can anticipate your family's absence?
Please select the dates in which we might anticipate your absence.*
Please use this space to explain what "other absent situation" means for your family during this week. [i.e. one child only, arrive late, leave early, etc.]*
Please list which child and attendance circumstance.
Are you interested in volunteering for GIDDY-UP?*
You can volunteer in a wide variety of capacities and according to your unique schedule.

Release & Waiver

Please read the following release and waiver. This must be agreed upon for your child(ren) to participate in DIVE-IN.
I, lawful parent of the child(ren) registered above, give permission for my child(ren) to participate in DIVE-IN VBS 2023 and release from all liability and indemnify the International Church of the Foursquare Gospel d/b/a Harvest Church and its directors, officers, council, agents, representatives, volunteers, and employees (“Church”) from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any damage, injury or illness incurred or caused by my child while participating in or traveling to or from the activity, or otherwise in Church custody. I understand the risks in these activities, including the possibility of unforeseen hazards, serious injury or death. I certify my child is able to participate in the activity.
Agree

Media Release

Please read the following release and select your consent.
I agree that Harvest Church may use my child’s and/or my own name, voice, portrait, photograph or image for promotional, website, office or any other church related purposes. These may be used in any broadcast, telecast, digital or print medium, including video images, photographs, pictures or renderings, audio recordings, or other likenesses, in combination or alone.
I CONSENTI DO NOT CONSENT

Parent/Guardian Signature

As Parent/Guardian of the registered child(ren) please sign to complete this registration.
Parent/Guardian Signature upon completing this form is required.
Should be Empty:

DIVE-IN Registration