VBS Registration 2023

Event Date & Time
June 12-16, 2023
1:00 PM - 5:00 PM

Event Location
St. Theodore's Episcopal Church
1001 Kingsland Dr, Bella Vista, AR 72714

ChristianEd@sainttheodores.com
Registration Information
1. Attendee's Name*
- Attendee’s Age
2. Parent's Name*
3. Parent's Email*
example@example.com
4. Parent's Phone Number*
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Emergency Contact #1 Name *
6. Emergency Contact #1 Phone Number *
Format: (000) 000-0000.
7. Emergency Contact #2 Name
8. Emergency Contact #2 Phone Number
Format: (000) 000-0000.
9. Attendee Allergies*
Youth SmallYouth MediumYouth LargexsMLXLXXL
11. Please share any special needs your child has or anything you would like us to know.

Photo Release
I _________________________________ am the parent or legal guardian of __________________________________ (“my child”), a participant of the Saint Theodore's Vacation Bible School (“VBS”), a program by Saint Theodore's Episcopal Church, held at St. Theodore’s Episcopal Church, located in Bella Vista, AR. I hereby consent to the publication and use of my child’s name and/or my child’s likeness (“Likeness”) for the purpose of promotion, publicity, advertising, or other manner or media by the Episcopal Churches in the Diocese of Arkansas (“Churches”), or any other representative authorized to act on behalf of the afore-mentioned entity. Likeness shall include, but not be limited to, photographs, sound and/or video recordings, films, broadcasts, brochures, publications, reports, web pages, promotional materials or any other audio-visual, electronic, printed, tangible work in any media or format, now known or hereafter to become known, and/or reproductions of any of these. I agree that the actual material involved is and shall continue to be the property of the Churches and that neither I, nor my child, shall have any right of review or approval regarding the use of my child’s name and/or Likeness in such material. I hereby release and hold harmless, the Churches along with their respective employees, agents, affiliates, sponsors, or other representatives from any and all claims, demands, or causes of action arising out of the use of my child’s name and/or Likeness, in accordance with the terms of this release. I understand and agree that neither I, nor my child, will be compensated in any way for the use of my child’s name and/or Likeness by the Churches.
I do agree to the above terms and allow the Churches to use my child's Likeness.I do not agree to the above terms, please do not use my child's Likeness in promotional materials.
Photo Release Signature*

Clear

Emergency Medical Treatment & Liability Waiver
In the event that my minor child, ___________________________________, has need of medical
attention, I do hereby give my permission for the staff and sponsors of the Saint Theodore's Episcopal Church Vacation Bible School to seek such help including emergency surgery if the particular medical emergency warrants. I understand that every effort will be made to contact me or my alternate responsible party prior to emergency surgical procedures, unless the particular situation does not allow due to the threat of loss of life.

I give my minor child full consent to attend the activities of the Saint Theodore's Episcopal Churche Vacation Bible School from June 12, 2023 to June 16, 2023 from the hours of 12:30 PM to 5:30 PM. It is my understanding that the staff and volunteers of the Saint Theodore's Episcopal Churches will take all of the necessary precautions to ensure the safety of my child. I do hereby release the above stated organization from any legal or financial obligation due to the injury of my above named minor.

Minor's Name: ______________________________________________________________________________________
Address: ____________________________________________________________________________________________
Parent/Legal Guardian Name: _______________________________________________________________________
Parent's Phone Number: _____________________________________________________________________________

Emergency Contact: _________________________________________________________________________________
Emergency Contact Phone Number: __________________________________________________________________

TRANSPORTATION ALLOWANCE
My above listed child is allowed to travel with Benton County Episcopal Churches in the transportation provided by the above named church.
I Agree
Signature of Parent or Guardian for Emergency Medical Treatment & Liability Waiver

Clear
Should be Empty:

Registration Information

Photo Release

Emergency Medical Treatment & Liability Waiver