VBS Registration 2025

VBS July 7 - 11 9:30-11:30 am Age 3-5th grade
Parent/Guardian:*

First NameLast Name
Additional Parent/Guardian:

First NameLast Name
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number:*
Format: (000) 000-0000.
E-mail:*

Confirmation Email
Church you attend (if any):

- FIRST CHILD
- Name:*
  
  First NameLast Name
- T-Shirt Size*
- Birth Date:*
  
  MonthDayYear
- Age:
- Grade Completed*
- Allergies/Medical Concerns
- SECOND CHILD
- Name:
  
  First NameLast Name
- T-Shirt Size
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed
- Allergies/Medical Concerns
- THIRD CHILD
- Name:
  
  First NameLast Name
- T-Shirt Size
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed
- Allergies/Medical Concerns
- FOURTH CHILD
- Name:
  
  First NameLast Name
- T-Shirt Size
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed
- Allergies/Medical Concerns
- FIFTH CHILD
- Name:
  
  First NameLast Name
- T-Shirt Size
- Birth Date:
  
  MonthDayYear
- Age:
- Grade Completed
- Allergies/Medical Concerns

Emergency Contact (other than primary guardian):*

First NameLast Name
Emergency Contact Phone:*
Format: (000) 000-0000.
Who will be picking up the child(ren):
Health Insurance Information
Insurance Holder :*

First NameLast Name
Health Insurance Company*
Policy Number*
Sponsor is authorized to approve medical treatment?*

Liability Release and Medical Consent

In consideration for the opportunity to participate in the Living Grace Church sponsored activity, the participant (or parent/legal guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during the transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representative (collectively referred to hereinafter as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant or otherwise.
Initials*
Please initial to indicate you have read and agree
Photo Use Agreement

I hereby grant, voluntarily and with full understanding, to Living Grace, a license to the following:
- Use and storage of the participant's name and image, by means of digital or film photography, video photography, audio recording or other documentation, with respect to the activity, namely this activity.
- Use of any stored data including the participant's name and image in printed or electronic publications of Living Grace.
Initials*
Please initial to indicate you have read and agree
By applying my electronic signature to this agreement, I agree that my electronic signature is the legally binding equivalent of my handwritten signature on paper. I will not, at any future time, claim that my electronic signature is not legally binding or enforceable. By electronically signing and submitting this agreement, I 1) acknowledge that I have read and fully understand the terms of the agreement; 2) voluntarily agree to be bound by this agreement; and 3) certify that I am 18 years of age or older. My signature applies to all pages of this contract. In order to print and retain a hard copy of this agreement, I understand that I will need a printer connected to my computer. I understand that if I wish to sign a hard copy of this agreement instead of an electronic version, I must contact the party that requires my signature on this agreement directly.
Parent/Guardian Signature:*

Clear
Date:

MonthDayYear

Hour MinutesAM/PM Option
Should be Empty:

VBS July 7 - 11 9:30-11:30 am Age 3-5th grade

FIRST CHILD

SECOND CHILD

THIRD CHILD

FOURTH CHILD

FIFTH CHILD

Health Insurance Information