2019 VBS Registration

How many children are you registering?*

Child's Name*

First NameLast Name

Child's Birth Date*

MonthDayYear

Child's Gender*

MaleFemale

Grade in Fall 2019*

Medical or other information we may need to know about the child (including food allergies). If nothing, please put "none."*

Child's Name*

First NameLast Name

Child's Birth Date*

MonthDayYear

Child's Gender*

MaleFemale

Grade in Fall 2019*

Medical or other information we may need to know about the child (including food allergies). If nothing, please put "none."*

Child's Name*

First NameLast Name

Child's Birth Date*

MonthDayYear

Child's Gender*

MaleFemale

Grade in Fall 2019*

Medical or other information we may need to know about the child (including food allergies). If nothing, please put "none."*

Child's Name*

First NameLast Name

Child's Birth Date*

MonthDayYear

Child's Gender*

MaleFemale

Grade in Fall 2019*

Medical or other information we may need to know about the child (including food allergies). If nothing, please put "none."*

Parent/Legal Guardian Names*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Family Doctor

Doctor's Clinic, Phone #

Insurance Provider

How is your child getting home?*

Dismissal plan for you child (please be as specific as possible)*

Names of person(s) to which your child(ren) may be released to each day after VBS. (Please note: we can only let your child(ren) leave with the people named here, besides a parent/guardian.)*

Provide first and last names

Emergency Contact (other than parent/guardian listed above)*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Relationship to Child(ren)*

I have full legal right and capacity to execute this document on behalf of my minor child(ren) named above.
In the event medical/dental care is required for my child(ren), reasonable efforts shall be made to contact me or another custodial adult listed above as soon as possible. In the event a parent/guardian cannot be reached, reasonable efforts shall be made to contact the emergency contact provided above.
If contact cannot be made, or if there is a medical emergency, I hereby authorize treatment of said child(ren) by a qualified and licensed doctor/dentist. An emergency is defined as an injury, illness, or physical condition which, in the opinion of the attending doctor/dentist, may endanger my child(ren)’s life, or cause disfigurement, impairment or undue discomfort if delayed. My agreement below further indicates my willingness to take full financial responsibility for any medical/dental or other expenses incurred by or on behalf of said child(ren). Claims may be submitted to my health insurance carrier.
I hereby release and agree to hold harmless GraceWay Church from any claims, responsibility or liability for decisions or actions taken pursuant to the Grant of Permission and Medical Authorization.

By clicking the box below, I agree to the permissions listed above.*

I Agree

I hereby give permission for photographs and/or video in which my child(ren) appears in to be used by the church in printed and/or electronic media, including the church's Facebook page and website.*

I AgreeI Decline

VBS Registration

Child Information

First Child

Second Child

Third Child

Fourth Child

Family Information

Dismissal Plans, Emergency Contact

Permission Release

Media Release