Crossroads Vacation Bible School

PLEASE NOTE: Seperate registration forms must be completed for each child participating in Vacation Bible School.

ALL FIELDS ARE MANDATORY

Child's Name

First NameLast Name

Child's Gender

MaleFemale

Child's Date of Birth

Date

Child's Age:

Primary Caretaker

First NameLast Name

Primary Caretaker Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Caretaker Email

example@example.com

Emergency Contact

First NameLast Name

Relationship

Emergency Contact Phone

Please enter a valid phone number.

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

YesNo

Please List or Explain

Please list all persons authorized to pick up your child and their relationship to the child. (ex. John Doe - Neighbor). In the event it is not a parent, please note a valid ID will be required at sign out.

Is there anything else you feel we should know about your child? (Any special medical or learning needs?)

Photography Waiver - I grant permission for photo(s)of my child to appear among other general youth photos as long as there is no identifying information shown. These photos may appear on the church website, used internally to share with the church congregation or on any church printed publications

My Child MAY have pictures taken of themMy Child MAY NOT have pictures taken of them

Social Media Waiver - I grant permission for photos of my child to appear on Crossroads Church's sponsored social media pages. Agreeing to this grants permission for us to use your child’s photo on social media that includes Facebook, Instagram, Twitter, Snapchat or any other internet outlet at which time others may tag your child in such posts if they have social media.

YesNo

Friday Evening, all family members are invited to celebrate with us at our Closing BBQ! Will your family be attending? (only one completed RSVP is needed, per family)

YesNo

How many will be attending the celebration BBQ from your family?

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Crossroads Church of Shamong during the selected Vacation Bible School period. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Crossroads Church of Shamong and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising during the VBS sessions. In case of injury to said child, I hereby waive all claims against Crossroads Church of Shamong including all leaders and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

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 child. 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 Crossroads Church of Shamong and its affiliates including leaders, teachers, 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 VBS. 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 AND SIGNING 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.

Caretaker Full Name

Date

Crossroads Vacation Bible School

Join us as we learn to put out Trust in Jesus at Camp Firelight!