Vacation Bible School Participant Registration
August 14-18 | 9 AM - Noon | Please fill out a registration form for each participating child.
Parent/Guardian Name
*
E-mail
This address will receive a confirmation email
Best Contact Phone
*
Second Phone
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Participant Name
*
Date of Birth
*
Gender
*
Please select one option.
Male
Female
Grade in Fall
*
Please select one option.
K
1
2
3
4
5
Allergies
Medical Limitations
Emergency Contact Name
*
Relationship to Participant
*
Emergency Contact Phone
*
Alternate Pick Up Person
Alternate Pick Up Person Phone
Alternate Pick Up Person
Alternate Pick Up Person Phone
Do you have a friend you want to be placed with? If so, who?
Additional Comments
Waivers, Releases & Certifications
Certification
*
Please select all that apply.
By checking this box I certify that I am the parent or legal guardian of the above named child and do hereby grant permission for said child to participate in Vacation Bible School (VBS), August 14-18, 2017
Waiver of Liability
*
Please select all that apply.
I do hereby release Palouse Federated Church and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in the VBS program.
Photographic Release
Please select all that apply.
I hereby grant Palouse Federated Church permission to use, for promotional purposes, photographs taken of the above named child, a participant in Vacation Bible School, August 14-18, 2017
Photographic Release
Please select all that apply.
I do not grant permission to Palouse Federated Church to use photographs taken of the above named child, a participant in Vacation Bible School, August 14-18, 2017 for promotional purposes of any kind.
Submit
Description
August 14-18 | 9 AM - Noon
Please fill out a registration form for each participating child.
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