2026 VBS Special Needs Participant Registration

Thank you for your interest in HCL's "Rainforest Falls" Special Needs Vacation Bible School!

Special Needs VBS is for individuals 3K to adults who have a disability. The "Rainforest Falls" week will kick off Monday, June 15th and last until Friday, June 19th from 9:30am-11:30am. We can't wait to see you!

Name Participant Goes By

Participant's Birth Date*

Date

Participant's Gender*

MaleFemale

Days that participant will be attending (mark all that apply)*

Help us keep your child safe! Select the days your participant CANNOT have the VBS snack due to a food allergy. Please provide a snack from home on those days. Questions? Email Bethany Dillon (bdillon@hcl.org).*

Monday: Quetzal Tails (Fruit by the Foot)Tuesday: Rainforest Animals (Members Mark animal cookies)Wednesday: Big Cat & Monkey Tails (Cheetos & pretzel sticks)Thursday: River Fish (multicolored Goldfish)Friday: Monkey Munch (pretzel sticks, chocolate chips, leftovers from previous days)My child can have the VBS snack each day.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name*

First NameLast Name

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

In case of a medical emergency involving the above named participant, I understand the following procedure will be followed: A reasonable effort will be made to contact me and secure my consent for any medical services. If I cannot be located within a reasonable time, the VBS coordinator has my permission to contact the participant's physician or emergency personnel. Marking yes shows that you agree with this statement.*

YesNo

Physician's Name*

First NameLast Name

Physician's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Insurance Policy Number*

Does the participant have a history of seizures?*

YesNo

If yes, please describe in detail.*

Will medication need to be administered during VBS? (Volunteer nurse will be onsite to administer it)*

YesNo

What is your participant's normal temperament?*

What makes your participant happy?*

Does your participant run away or wander?*

YesNo

Does your participant have any behaviors that are particularly challenging?*

YesNo

If yes, please describe the behavior and what helps to calm them.*

Music is an important part of our VBS. Please indicate your child's best reaction to music.*

Enjoys musicSensitive to loud musicFrightened by music

Any additional information that will help us make this experience a positive one.

Does HCL have permission to take and use photos/video of your child for future publicity of VBS and/or HCL's Special Needs Ministry?*

YesNo

How did you hear about Special Needs VBS?

Liability Disclosure: Every activity sponsored by Hales Corners Lutheran Church and/or the Hales Corners Lutheran Family of Schools (hereinafter “Church”), is carefully planned and adequately supervised by mature adults. However, even with the best planning and precaution, unforeseen events can occur. This disclosure is made to all participants, whether through his/her parent or guardian or as an adult on his/her own behalf, to inform them they assume all risk of damage, loss, or injury to the person or property for which the Church and its employees and volunteers are not negligent.

By my initials, I indicate that I have read and understand this statement:*

The prices below include a non-refundable 3% convenience fee.

Payment*

Special Needs VBS Participant

$20.00

Enter coupon

Total

$0.00

Credit Card