VBS Registration Form
June 23-25, 2026
Name of Primary Parent/Guardian
First Name
Last Name
Name of Secondary Parent/Guardian
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number #1
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number #2
Please enter a valid phone number.
Format: (000) 000-0000.
Registration fee is $10/child or $30/family. This can be paid on the first day of VBS or any time before then at the parish office. Financial Assistance is available. Reach out to Emily Priest at knoxvillestanthonydre@diodav.org for more information. For more children, you may contact the office or fill-in a second form.
Rows
Names of Child(ren)
Allergies, Medical Conditions, Food Restrictions
Grade in 2026-2027
1
2
3
4
5
6
Additional Emergency Contact Information
Name & phone number of an adult to reach in case of emergency in the event that you cannot be reached at the numbers above.
Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Authorization
In case of an emergency where your child would need to be taken to the hospital, this information is helpful for the attending hospital.
Name of Family Physician
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company
Policy #
I understand that the Diocese of Davenport and St. Anthony's Catholic Church assume no responsibility for accidents which may occur in association with diocesan events and activities. I agree to use my/our personal insurance to cover any such incidents. I understand that, in the event medical intervention is needed, every attempt will be made to contact the persons listed above. In the event those individuals cannot be reached, I/We hereby give permission to the physician or any other qualified medical staff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia, or surgery for Participant as deemed necessary.
Release of Liability for Youth & Adults
I understand all reasonable safety precautions will be taken at all times by the Diocese of Davenport and St. Anthony's Catholic Church and its employees and agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Diocese and St. Anthony's Catholic Church, its leaders, employees and volunteer staff from any and all claims arising from or in connection with attending this event.
Code of Behavior for Youth & Adults
I agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/ representatives. I agree that if I/Participant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the event and sent home immediately at my/Participant's expense with no right of reimbursement or refund for any amount in connection therewith from the Diocese of Davenport or its chaperones/representatives.
Photo Release
YES, I hereby authorize the Diocese of Davenport and St. Anthony's Catholic Church and its agents to utilize photographic and/or video images of me or my child by the Diocese of Davenport. In giving my consent, I hereby indemnify and hold harmless the Diocese of Davenport and St. Anthony's Catholic Church and its agents from any and all responsibility of liability. I understand that I will receive no compensation should any photograph and/or video of me or my child be used.
Signature of Parent/Guardian
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: