Vacation Bible School Registration Form

Name(s) of Child(ren) Attending:*

Name of Person Filling Up This Form*

First NameLast Name

Relationship to Child(ren) Attending:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Please enter a valid phone number.

Secondary Phone Number

Please enter a valid phone number.

EMERGENCY CONTACTS
Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.

Primary Contact*

First NameLast Name

Relationship to child*

Phone Number*

Alternate Contact

First NameLast Name

Relationship to child

Phone Number

MEDICAL INFORMATION

Please list all allergies -- or type "none" if there are none*

Does your child carry an epi-pen? (please note: if yes, it is the responsibilty of the child's guardian to ensure the child has the epi-pen at every drop off and pick up)*

YesNo

Please list all medical concerns -- or type "none" if there are none*

VBS ACKNOWLEDGEMENT & WAIVER AGREEMENT

I am the parent/legal guardian of the child(ren) listed above and I am aware that my child(ren) will be participating in the Vacation Bible School (VBS) of Regency Baptist Church (RBC) located at 3300 Taylor Rd., Loomis, CA.

I agree and declare that I understand the scope of VBS activities and I consent to the participation of the above-named child(ren) in these activities.

I understand that certain activities may result in physical injury to my child(ren) but nonetheless specifically request that he or she be allowed to participate in those activities.

In the event of an emergency, I or any of my emergency contacts listed above, may be reached at the telephone numbers listed above. In the event that I or my emergency contacts can not be reached, I hereby authorize RBC and its staff, employees, drivers, sponsors, VBS volunteers and/or helpers to take any steps they deem necessary to obtain emergency medical care for my child(ren) and I hereby release RBC and it’s representatives from any financial liability incurred during such emergency treatment.

I hereby grant permission to RBC, staff and representatives to utilize my/my child(ren)’s name, likeness, voice and biographical material in connection with the publication, promotion, exhibition and distribution of promotional material. I understand that no royalty, fee or any other compensation of any kind shall become payable to me by reason of such release and use of any photograph, audio and/or video.

I confirm that all information in this form is accurate and true to the best of my knowledge.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED AT THE VBS, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO, AS WELL AS TRANSPORTATION TO AND FROM. I do hereby agree to hold Regency Baptist Church, its agents and employees, as well as VBS volunteers/helpers harmless from any and all liability, actions, causes of actions, claims, expenses and damages on account of injury to my child(ren) or property, even injury resulting in death, which I now have or which may arise in future in connection with the VBS or participation in any other associated activities.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understood.

Name*

First NameLast Name

Signature*

Date*

Date

Vacation Bible School Registration Form

EMERGENCY CONTACTSPlease list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.

MEDICAL INFORMATION

VBS ACKNOWLEDGEMENT & WAIVER AGREEMENT

EMERGENCY CONTACTS
Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.