SHINE Super Saturday Vacation Bible School Registration Form
Welcome Church of God, Saturday, August 1st, 10am - 2pm
Please fill out this form for each child you are registering. This is for your child’s safety. For example, if you are registering three children, fill the form out three times once for each child. Thank you!
Child Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Current Grade Level
Grade level on next school year
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 have other siblings that will be attending? If so, please provide their name(s):
Does the child currently taking medications they may need? 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
Parent/Guardian
First Name
Last Name
Relationship to Child
Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact Information
Emergency Contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relation to child(ren)
Other than parent/guardians, please list any other adult(s) that may pick up your child(ren).
Adult #1
First Name
Last Name
Adult #2
First Name
Last Name
Adult #3
First Name
Last Name
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Submit
Submit
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Terms and Conditions
I allow my child to participate in the Super Saturday VBS program at Welcome Church of God.
I hereby authorize the church, pastor, VBS coordinator, or 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 and church 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?
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Should be Empty: