2024 Special Needs VBS Participant Registration

Special Needs Vacation Bible School Registration

June 17-21, 2024
Thank you for your interest in HCL's "Scuba" Special Needs Vacation Bible School!

Special Needs VBS is for individuals 2 years or older (including adults) who have a disability. The "Scuba" week will kick off Monday, June 17th and last until Friday, June 21st from 9:30am-11:30am. We can't wait to see you!
Participant's Name*

First NameLast Name
Name Participant Goes By
Participant's Birth Date*

MonthDayYear
Participants Gender*

FemaleMale
Days that participant will be attending (mark all that apply)*

MondayTuesdayWednesdayThursdayFriday
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
In case of a medical emergency involving the above named participant, I understand the following procedure will be followed: A reasonable effort will be made to contact me and secure my consent for any medical services. If I cannot be located within a reasonable time, the VBS coordinator has my permission to contact the participant's physician or emergency personnel. Marking yes shows that you agree with this statement.*

YesNo
Physician's Name*

First NameLast Name
Physician's Phone Number*
Please enter a valid phone number.
Insurance Policy Number*
Does the participant have a history of seizures?*

YesNo
If yes, please describe in detail.*
Will medication need to be administered during VBS? (Volunteer nurse will be onsite to administer it)*

YesNo
What is your participant's normal temperament?*
What makes your participant happy?*
Does your participant run away or wander?*

YesNo
Does your participant have any behaviors that are particularly challenging?*

YesNo
If yes, please describe the behavior and what helps to calm them.*
Music is an important part of our VBS. Please indicate your child's best reaction to music.*

Enjoys musicSensitive to loud musicFrightened by music
Any additional information that will help us make this experience a positive one.
Does HCL have permission to take and use photos/video of your child for future publicity of VBS and/or HCL's Special Needs Ministry?*

YesNo
How did you hear about "Scuba" VBS?
Liability Disclosure: Every activity sponsored by Hales Corners Lutheran Church and/or the Hales Corners Lutheran Family of Schools (hereinafter “Church”), is carefully planned and adequately supervised by mature adults. However, even with the best planning and precaution, unforeseen events can occur. This disclosure is made to all participants, whether through his/her parent or guardian or as an adult on his/her own behalf, to inform them they assume all risk of damage, loss, or injury to the person or property for which the Church and its employees and volunteers are not negligent.
By my initials, I indicate that I have read and understand this statement:*

Payment*

Special Needs VBS Participant

$20.00

Enter coupon

Total

$0.00

Credit Card

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Special Needs Vacation Bible School Registration

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