BETHANY 2026 VBS REGISTRATION

BETHANY CHURCH VBS REGISTRATION

June 20, 2026 10:00 AM-3:30 PM
Child's Name

First NameLast Name

Birth Date

MonthDayYear
Grade just finished
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Has your child been prescribed an inhaler or epi-pen? If yes, it is the responsibility of the child's guardian to ensure the child has the epi-pen at drop off and pick up.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Bethany Church during VBS. In exchange for the acceptance of said child’s candidacy by Bethany Church, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Bethany Church and all its respective officers, agents, and representatives from any and all liability for injuries to said child.

In case of injury to said child, I hereby waive all claims against Bethany Church including all leaders and affiliates, all participants, 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.

Release authorized on the dates and/or duration of the registered season.

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.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
DO YOU ALLOW YOUR CHILD TO BE INCLUDED IN PHOTOS/VIDEOS? PHOTOS/VIDEOS MAY APPEAR ON THE CHURCH FACEBOOK PAGE.
Should be Empty:

BETHANY CHURCH VBS REGISTRATION