Local Food Summit Registration Form

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Child's Age*

Child's Gender*

MaleFemale

Child's Race*

Is your child of Hispanic or Latino descent?*

YesNo

Is English the primary language spoken in your home?*

YesNo

If NO, what is the primary language?

Child's School*

Child's Grade Level, 2023 - 2024 School Year*

(Must be 1st - 5th grade)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name #1*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Parent/Guardian Name #2

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Emergency Contact #1*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Child*

Emergency Contact #2

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Child

Does your child have any medical conditions that we need to be aware of?*

YesNo

If yes, please explain.

(We CAN NOT administer any medication.)

Does your child have any allergies (food, seasonal, and/or insect) or food restrictions?*

YesNo

If yes, please explain.

(Your child will be provided lunch.)

Do you give VBF permission to photograph and/or video your child?*

YesNo

(This will be used for documentation, education, and marketing purposes.)

What day(s) will your child be attending?*

Friday, December 1stSaturday, December 2nd

Will your child be attending all day on the above chosen day(s)?*

YesNo

If NO, please explain.

Is there any additional information you feel we need to know about your child?

Please read each statement and sign below.

My child is to listen and be respectful to all personnel and his/her peers at ALL times.
Transportation IS NOT provided! My child is to be picked up and dropped off ON TIME!
I am responsible for signing my child in and out each day. At pick up, I am required to show a valid photo ID. If I am unable to pick up my child, the persons listed as Parent/Guardian #2 and emergency contacts will show a valid photo ID and have permission to sign out my child.
I understand that all risks associated with participating in the BeHealthy Kids Tennessee Local Food Summit Program, including but not limited to, bodily injury are assumed by me. I will be notified in case of emergency. If I cannot be reached, I authorize medical treatment deemed necessary by medical professionals.

Failure to adhere to this information can lead to this dismissal of my child from the BeHealthy Kids Tennessee Local Food Summit Program. By signing below, I am stating that I have read and completed the above information accurately.

Signature*

Date*

Date

This camp is provided by Vine Branch Fellowship, a 501(c)3 charitable nonprofit organization, in partnership with Tennessee Local Food Summit and Cumberland University.

P.O. Box 267 Gladeville, TN 37071

www.VineBranchFellowship.org

Tennessee Local Food Summit Registration