VBS Detailed Registration Form

Student Information

Name

First NameLast Name

Birth Date

MonthDayYear

Grade Entering (PreK/K- enter 0)

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

example@example.com

Would you like to be added to receive emails for upcoming Harmony Grove events?

Do you have a home church?

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Who is authorized to pick up your child(ren)

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Harmony Grove Community Church (HGCC) during the selected camp. In exchange for the acceptance of said child’s candidacy by HGCC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless HGCC and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising from participating in camp sessions.

In case of injury to said child, I hereby waive all claims against HGCC including all counselers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Harmony Grove Community Church (HGCC) and its affiliates including Directors, and Church Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Photograph Release

This Photography Permission Form and Release (the "Release") is provided to Harmony Grove Community Church ("HGCC") regarding any photographs that are taken of me /us and my / our children (if we have children who participate in activities at HGCC) (the "Photographs"). The Photographs will become the property of HGCC and I / we grant HGCC the right to use the Photographs, or derivative works thereof, for the following purposes without charge: to put on HGCC’s website; to include in HGCC's newsletters or other HGCC literature; to post on bulletin boards or posters at HGCC; to use in Power Point presentations or videos that are shown at HGCC, on HGCC’s website, or at Christian functions in which HGCC participates.

You hereby agree that you will not bring or consent to others bringing claim or action against HGCC on the grounds that anything contained in the Photographs, or in the advertising and publicity used in connection therewith, is defamatory, reflects adversely on you, or violates any other right whatsoever, including, without limitation, rights of privacy and publicity. This Release shall not obligate HGCC to use the Photographs, or to use any of the rights granted hereunder, or to prepare, produce, exhibit, or distribute the Photographs.

I have read and voluntarily signed this Release, Waiver of Liability and Indemnity Agreement, and Photography Release, I agree that it embraces each and every event sanctioned, authorized, or promoted by or within the Harmony Grove Community Church, whether by the Harmony Grove Community Church directly or any other person or entity.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Electronic Signature-

Please type in your name above

2026 Vacation Bible School