Wacky Wednesday 2026 Signup Form
A Bible Based Summer Program at Miller's Chapel United Methodist Church
Name of the Child
*
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Age
*
Ages 10 through teens accepted
Gender
Male
Female
Grade Level
Please Selecti
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Is he/she carrying an Epi-pen at all times?
*
Yes
No
Does your child have any allergies?
*
Yes
No
What are the allergies of your child?
Does your child have any medical condition that we should be aware of?
*
Yes
No
What is this medical condition? Please elaborate below including restrictions and instructions if we need them:
Pick Up Authorization
Authorized person/s to pickup your child after the Vacation Bible Study
Full Name 1
*
First Name
Last Name
Relationship
*
Full Name 2
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.
Reminders to families
***Special note to participants - there will be a posted Code of Conduct for each one to sign on their first day of Wacky Wednesday. Please refer to the image below.
I allow my child to participate in this program.
I hereby authorize the school, 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. (For in-person)
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.
Would it be okay if we take photos and videos of the participant during the activity which will be posted in our social media account?
*
Yes
No
Parent/Guardian Signature
*
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: