VBS Registration Form

Vacation Bible School Registration
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Gender*

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Authorization to Pick Up Child

I hereby inform Atlanta Southside SDA Church that the people listed below are authorized to pick up the above named child at any time. Accordingly, Atlanta Southside SDA Church is hereby instructed to release my child into the care of the following people whenever they come to the Center.
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Atlanta Southside SDA Church during the selected camp. In exchange for the acceptance of said child’s candidacy by Atlanta Southside SDA Church, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Atlanta Southside SDA Church and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Atlanta Southside SDA Church.
Media Release and Authorization

As Parent and/or Guardian of the named child, I grant permission for Atlanta Southside SDA Church to take photos/video of my child(ren) during church events and to use these images in church publications, website and social media. I understand that photos and videos will NEVER be accompanied by captions or tags that include names or any other identifying information.
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