Route 105 An Adventure in Faith
Join us for a fun outside adventure as we discover God’s Road Map for life! Three dates and locations throughout the summer, come to one or come to all three! Games, crafts, fun music and more! Bag lunches provided Must have completed Kindergarten. This is a drop off event, registration required.
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I am registering my child for:
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If attending two of the events, which two?
First Name *
Last Name *
Date of Birth *
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Grade attending in 22-23 School Year (Must have completed Kindergarten) *
Address *
Zip *
Parent/Guardian Information
Guardian #1: *
Guardian #1 Cell Number: *
Guardian #1 Work or Alternative Phone Number
Guardian #1  email:
Guardian #2:
Guardian #2 Cell Phone Number:
Guardian #2 Work or Alternative Phone Number
Guardian # 2 Email:
If above persons cannot be reached in the event of an Emergency notify: *
Phone Number for Emergency Contact: *
Restrictions, Allergies, Medical Information:
Has your child ever had a severe reaction to a bee/hornet sting or insect bite? *
If yes, please explain:
Does your child have any food allergies or special dietary requirements? *
If yes, please explain:
Does your child have any medical conditions or any special considerations we need to be aware of?
Type full name (permission for over the counter medications)
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I __________________ give my authority and consent to the Shenandoah District's sponsors/leadership to seek a doctor or qualified person to provide emergency medical treatment to the above named student in the event he/she is ill or injured while participating at Route 105 VBS  I, undersigned parent/ guardian of the above mentioned child who is a minor, do realize, acquit, discharge and covenant to hold harmless its sponsors and representatives from any and all actions, cases of actions, damages, and/or liabilities arising from the medical treatment of any sickness or injuries from and accident incurred by my said child during the event.  (Type full name)
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I give my authority and consent to the Wesleyan Shenandoah District sponsors/leadership to take pictures of my child while at this event.
Signature of Parent/Guardian: *
Date: *
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