Vacation Bible School Registration Form

Date: June 4th - 8th, 2018
Time: 9:30am - 12:30pm
Location: Reid Memorial Presbyterian Church
Eligible Participants: Rising PreK - 5th Grade Students
Pre-Registration Deadline: Friday, May 25

Child's Name

First Name Last Name

Entering Grade

D.O.B.

Sex

Male Female

Parent/Guardian

First Name Last Name

Phone Number

- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email

example@example.com

Relation to Child

Phone Number

- Area Code Phone Number

Medical Conditions/Allergies

Yes No

If yes, please explain:

Please list any dietary or activity restrictions:

Is child on medication?

Yes No

Specify medication and dosage:

Physician Name

First Name Last Name

Phone Number

- Area Code Phone Number

Medical Insurance Company

Phone Number

- Area Code Phone Number

My child may be released to (other than parent/guardian)

First Name Last Name

Phone Number

- Area Code Phone Number

Relation to Child

Church Home/Affiliation

First Aid and Emergency Medical Treatment:

I recognize that there may be occasions where my child may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. thereby give permission for agents of Reid Memorial Presbyterian Church to seek and secure any needed medical attention or treatment for the child name above should such need arise.

Publicity Release:

On occasion, Church of the Good Shepherd takes photographs or makes audio or video recordings of children and/or adults involved in church activities. Such photographs or recordings may be used by staff and participants to remember the activities, and may be used in the church's publications or advertising materials to let others know about its ministry. The church may also invite local news organizations to photograph or record our events for news reporting or special interest features. I consent to the use of any such photograph or audio or video recording of the child named above to be used, distributed, or displayed as agents of the church deem appropriate.

Release of Liability:

By signing below, I expressly warrant that my child is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release Reid Memorial Presbyterian Church and its ministers, leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in these activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against Reid Memorial Presbyterian Church or its ministers, leaders, employees, volunteers, or agents.

Vacation Bible School Registration Form

Emergency and Medical Information