Vacation Bible School Registration Form
Henderson Church of The Nazarene
Child Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Current Grade Level
*
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the child have any allergies? If yes, please list them below:
Does the child currently taking medications? If yes, please list them below and provide the reason:
Does the participant have any medical condition that we should be aware of? If yes, please explain below:
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Parent / Guardian Information
Name
*
First Name
Last Name
Relationship to Child
*
Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Terms and Conditions
I allow my child to participate in this program.
I hereby authorize representatives from the church to conduct first aid, and medical care in the event of an emergency situation.
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 during the activities of your child that could possibly be posted on social media?
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: