VBS Registration - 4th Street Church of the Brethren
June 12-16, 2023, 9:00am - 11:30am
Age 4 - 5th Grade
4th Street Church of the Brethren, 260 South Fourth Street, Chambersburg, PA
Contact us at (717) 264-6957 or gretchen@chambcob.org
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Email *
Child's Name *
*Please complete a separate form for each child
Child's Gender *
Child's Address *
Grade Completed This Year *
Child's Age *
Home Church
Dietary Restrictions and Allergies *
*For specific allergies, please check other and list all allergies
Required
We try to pair children with ONE friend. Please assign my child with:
*We will do our best to accommodate one friend request. Please include first and last name of one friend.
Emergency Contact Name *
Emergency Contact Relationship to Child *
Emergency Contact Phone Number *
Release Form
Release Form:

I release adult supervisors and Chambersburg Church of the Brethren from responsibility for accidents during church sponsored activities. In case of emergency, I, the parent/legal guardian of the above mentioned minor, give permission to the adult sponsors of Chambersburg Church of the Brethren to secure proper treatment for the health and comfort of my child until I can be reached.

Photo Release:

I give permission to Chambersburg Church of the Brethren to photograph and video record my child at Evening WithOut Kids. I give permission to copyright, use, and publish the photographs and video for any lawful purpose, including newspaper articles, church publications, and the church website. I have read and understand the above:

Signature *
By signing this form you give consent to the above Release and Photo Release statements.
A copy of your responses will be emailed to the address you provided.
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