2019 Vacation Bible School Participant Registration

August 5-9 | 9 AM - Noon | Please fill out complete information for all participating children.

Parent/Guardian Name

E-mail

This address will receive a confirmation email

Best Contact Phone

Second Phone

Address

Participant 1 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

Participant 2 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

Participant 3 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 children and do hereby grant permission for said children to participate in Vacation Bible School (VBS), August 5-9, 2019.

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: 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 5-9, 2019

Please select one option.

Yes No

Description

August 5-9 | 9 AM - Noon

Please fill out complete information for all participating children.

2019 Vacation Bible School Participant Registration

Description

Please Fix the Following