2024 VBS Registration Form

Vacation Bible School Registration

2024
Child's Information

List all children attending VBS from the same household (up to 4 per form). For Grade, please list the grade your student just completed during the 2024 school year.
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
MaleFemale
#2 Child's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
MaleFemale
#3 Child's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
MaleFemale
#4 Child's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
MaleFemale
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the #1 CHILD have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Does the #2 CHILD have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does the #3 CHILD have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does the #4 CHILD have any allergies, chronic illness, or medical conditions? If yes, please describe.
Dismissal Information - Who may pick up your child(ren) at the end of each VBS day?*
Other Information - Does your child(ren) attend Sunday School? If so where?
If your child(ren) is visiting our church, who are they a guest of?
YesNo
YesNo
LIABILITY RELEASE:

In consideration of Holly Springs Baptist Church allowing the above child(ren) to participate in Vacation Bible School activities, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless Holly Springs Baptist Church its directors, employees, volunteers, and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above child(ren) while involved in Vacation Bible School. Furthermore, on behalf of my minor child(ren), I hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in activities involved therein. As well as releasing the child(ren), if necessary, for transportation to and from the Vacation Bible School location, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless Holly Springs Baptist Church, its directors, employees, volunteers, and agents from any and all liability, claims or demands for accidental personal injury in the process of transportation.
MEDICAL TREATMENT PERMISSION/strong>

I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) pursuant to this authorization.
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.
Date

MonthDayYear
Date
Signature

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Vacation Bible School Registration

Child's Information