Vacation Bible School Registration 2023

JULY 31 THROUGH AUGUST 3, 2023

8 a.m. to 12 Noon

CHURCH OF THE TRANSFIGURATION

25225 Code Road

Southfield, MI 48033

Childs Name*

First NameLast Name

Gender*

MaleFemale

Birth Date*

MonthDayYear

Age*

Grade Completed This Year*

Must be entering grade one or older

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Youth T-Shirt Size

XS (4-6)S (6-8)M (10-12)L (14-16)

Family E-Mail*

example@example.com

Parent/Guardian Information

Name (Father)

First NameLast Name

Contact Number (Father)

Area CodePhone Number

E-mail (Father)

example@example.com

Name (Mother)

First NameLast Name

Contact Number (Mother)

Area CodePhone Number

E-mail (Mother)

example@example.com

MEDIA CONSENT

My child may be photographed for parish educational and community relations not-for-profit use such as newsletter articles, parish bulletin, community newspaper articles, website, etc.

MEDIA CONSENT*

YESNO

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number (must be available during all VBS hours)*

Area CodePhone Number

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Parents must provide snack food for children with food allergies, in a bag CLEARLY marked for your child.

All medications are turned into Diane with name, written authorization and instructions about dispensing the medication.

Is the child prescribed an inhaler? If yes, please explain any instructions.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by the Church of the Transfiguration during the 2023 Vacation Bible School. In exchange for the acceptance of said child’s registration by the Church of the Transfiguration, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Church of the Transfiguration, its sister churches of the Family Sent on Mission and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising during the Vacation Bible School sessions.

In case of injury to said child, I hereby waive all claims against the Church of the Transfiguration, and the churches of the Family Sent on Mission, including all leaders and affiliates, all participants, and the Roman Catholic Archdiocese of Detroit.

Medical Release and Authorization

As Parent and/or Guardian of the named child, 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 Church of the Transfiguration and its affiliates including leaders, clergy, staff and catechists, 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 Vacation Bible School.

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, ENTERING MY NAME AND SUBMITTING 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.

Electronic Signature*

full name and relationship to child

Date*

Date

Payment will be made by the first VBS session.

$35 one child$70 total two children$85 total three or more children

Pay via cash or check by mail or by the first day of the Vacation Bible School.

Church of the Transfiguration

c/o Diane Klucka

25225 Code Road

Southfield, MI 48033

VBS REGISTRATION FORM