VBS & Teen Week REGISTRATION FORM (AGES 4-18)
A summer experience full of fun, laughter, and lots of God’s Word!
Name of Child
First Name
Last Name
Parent Name
First Name
Last Name
Age
Please Select
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Gender
Male
Female
Grade Level
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Street Address
Street Address Line 2
City
State/Province
Zip Code
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
NCC Campus Affiliation
Please Select
NCC-Dothan
NCC-Safe Harbor
Other
Is he/she carrying an Epi-pen at all times?
Yes
No
Does your child have any allergies?
Yes
No
Does your child have any medical conditions that we should be aware of?
*
No
Yes
Please describe if your child has special needs so we can determine if we have adequate staffing to accommodate the need.
Pick Up Authorization
Authorized person/s to pickup your child after Vacation Bible School
Name
First Name
Last Name
Relationship
Name
First Name
Last Name
Relationship
Emergency Contact Information
Emergency Contact 1
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
VBS are during the following dates: PLEASE SELECT THE CORRECT CAMPUS!
What days will your child be in attendance for Dothan's Teen Week?
NCC DOTHAN - JUNE 9 (6:30-9:30 PM)
NCC DOTHAN - JUNE 10 (5:00-8:00 PM)
NCC DOTHAN - JUNE 11 (5:00-8:00 PM)
NCC DOTHAN - JUNE 12 (10:00-5:00 PM)
NCC DOTHAN - JUNE 13 (10:00-1:00 PM)
What days will your child be in attendance?
NCC DOTHAN - JUNE 10 (5:00-8:00 PM)
NCC DOTHAN - JUNE 11 (5:00-8:00 PM)
NCC DOTHAN - JUNE 12 (10:00-2:00 PM)
What days will your child be in attendance?
NCC SAFE HARBOR - JUNE 10 (5:00-8:00 PM)
NCC SAFE HARBOR - JUNE 11 (5:00-8:00 PM)
NCC SAFE HARBOR - JUNE 12 (VBS Finale Fest, 6:00-7:30 PM)
Authorizations
By signing this form, I agree to the following statements.
Would it be okay if we take photos and video of your child during VBS to be posted to our social media account?
Yes
No
I allow my child to participate in the Northview Christian Church's Vacation Bible School and/or Dothan Teen Week.
I
hereby authorize Northview Christian Church, KOC Directors, and KOC volunteer
personnel to conduct first aid and medical care in the event of an emergency
situation. I agree to pay for all medical care expenses and costs in any
situation that medical care is needed.
I
release the organizers from any liabilities that might occur during the activity
and hold them harmless in the event of damages, injuries, or accidents.
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Submit
Should be Empty: