Mountain of Miracles VBS

God's Love is Rock Solid
1300 Herr St. Harrisburg, Pa 17103

July 28 , 2025 to Aug 1, 2025 5:45-8:30 (Special Program featuring the kids Aug 2nd @11am)
Child Name

First NameLast Name
Age
Gender
Date of Birth

MonthDayYear
Date
Grade level on next school year
Does the child have any allergies or special needs? If yes, please list them below:

Parent / Guardian Information
Name

First NameLast Name
Relationship to Child
Telephone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transportation

Child will walk homeChild will be picked up
If the child will be picked up by someone other than the parent, please list the name and phone number of the pick up person.

Terms and Conditions
- I allow my child to participate in this program.
- I hereby authorize the church, bible study conductor, volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.
- I release the organizers from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
- I confirm that all information in this form is accurate and true to the best of my knowledge.
Do you allow the organizers to take photos or videos during the activities of your child for advertising and marketing purposes that will be posted on social media?

YesNo
IMPORTANT- Please be prepared to show ID at time of pick up. Thank you in advance for your cooperation.
Parent/Guardian Signature

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Date
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God's Love is Rock Solid