VBS Registration
Name
Prefix
First
Last
Suffix
Gender
 Male 
 Female 
Age
Birthdate

MM		/
DD		/
YYYY
Grade Just Completed
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Siblings also attending VBS
Parent/Guardian Name
Prefix
First
Last
Suffix
Phone Number

###		-
###		-
####
Cell Number

###		-
###		-
####
Emergency Contact
Prefix
First
Last
Suffix
Relationship to Child
Phone Number

###		-
###		-
####
Emergency Contact
Prefix
First
Last
Suffix
Relationship to Child
Phone Number

###		-
###		-
####
Does your child have any medical conditions (allergies, medication, etc...)?
 Yes 
 No 
If Yes, Please explain.
Insurance Company
Policy #

Release of Liability

By submitting this registration I give permission for my child/ward to participate in the above named activity and release Grace on the Ashley Baptist Church, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by myself or any member of my family, in attendance, and I agree to defend and indemnify Grace on the Ashley Baptist Church, its officers, employees, and agents from any liability or loss they might sustain by reason thereof. In the event I cannot be reached in an EMERGENCY, I hereby give permission for the physician selected by the Director of Children's Ministry to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child/ward as named above.
Submission Date

MM		/
DD		/
YYYY

Permission for Media Release

By submitting this registration I agree that any photographs or video taken of my child/ward at or during this event are the property of Grace on the Ashley Baptist Church and may be used in future publications or media productions as deemed appropriate.
Submission Date

MM		/
DD		/
YYYY
Image Verification
captcha
Please enter the text from the image:
[Refresh Image] [What's This?]
Powered byEMF Contact Form
Report Abuse