Where Jesus Is Always With Me
1300 Herr St. Harrisburg, Pa 17103
July 15, 2024 to July 19, 2024 6:00-8:30 (Special Program featuring the kids July 20th @11am)
Child Name
First Name
Last Name
Age
Gender
Date of Birth
-
Month
-
Day
Year
Date
Current Grade Level
Grade level on next school year
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Does the child have any allergies? If yes, please list them below:
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Parent / Guardian Information
Name
First Name
Last Name
Relationship to Child
Telephone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Terms and Conditions
I allow my child to participate in this program.
I hereby authorize the church, bible study conductor, volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.
I release the organizers from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Do you allow the organizers to take photos or videos during the activities of your child for advertising and marketing purposes that will be posted on social media?
Yes
No
I would like to participate in the parent portion of Vacation Bible School including dinner.
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: