Hosted by Union Avenue Christian Church, Mt. Zion Lutheran Church, and Beacon Church
Held at Union Avenue Christian Church - 422 E Union Avenue, Litchfield IL 62056 Pre-Registration closes Sunday, June 22, 2025
Child's Name
*
First Name
Last Name
Child's Birth Date
*
Child's Age
*
Grade Entering in Fall
*
Please Select
Pre-K 3 (must be potty trained)
Pre-K 4 (must be potty trained)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Parent/Guardian Name - 1
*
First Name
Last Name
Parent/Guardian Name - 2
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Back
Next
Emergency Contact Information
Emergency Contact 1
*
First Name
Last Name
Relation to Child
*
Emergency Contact 1 - Phone Number
*
Please enter a valid phone number.
Emergency Contact 2
*
First Name
Last Name
Relation to Child
*
Emergency Contact 2 - Phone Number
*
Please enter a valid phone number.
Primary Care Physician
*
If non-applicable type "NA"
Last Name
Primary Care Physician Phone Number
*
If non-applicable enter all zeros
Allergies or Dietary Restrictions - If none type "N/A"
*
Back
Next
Consent & Liability Waiver
I grant permission for my child to participate in the 2025 Team Jesus VBS at Union Avenue Christian Church on Sunday, June 29, 2025.
*
Date
*
I will not hold Union Avenue Christian Church, its employees, volunteers, or anyone acting on its behalf, responsible or liable for injury occurring to the named person in the course of such activities.
*
Date
*
Please Choose one for Sunscreen Application
*
As the parent or legal guardian of the above named child, I hereby give my permission to Union Avenue Christian Church, it's employees and volunteers to apply a sunscreen product of SPF 15 or higher to my child, as specified below, when he or she will be engaging in outdoor activities between the times of 10:00AM and 4:00PM. I understand that sunscreen may be applied to exposed skin, including but not limited to the face, tops of ears, nose, bare shoulders, arms, and legs.
As the parent or legal guardian of the above named child, I hereby DO NOT give my permission to Union Avenue Christian Church, it's employees and volunteers to apply a sunscreen product to my child.
Photo & Video Release for Minors (under 18)
*
Union Avenue Christian Church and has my permission to use my child’s photographs and video footage publicly promote the church and/or VBS. I understand that the images and video clips may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of use.
Union Avenue Christian Church DOES NOT have my permission to use my child’s photographs and video footage publicly to promote the church and/or VBS. I understand that the images and video clips may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of use.
Continue
Continue
Should be Empty: