VBS Registration
Event Dates and Time: July 15-19, 9:00-11:30am
Location: Waushara Community Church (WCC), N2126 22nd Ave, Wautoma, WI
For: K4-6th Graders
Contact Us: 920-787-7148
Email: kidsmin@wausharacommunitychurch.org
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Student’s Last Name *
Student's First Name  *
Gender *
Boy
Girl
Select one
Student's Grade as of September 2024 *
K4
K5
1st
2nd
3rd
4th
5th
6th
Select one
Student's Birthdate including year *
AllergyMedical/Learning Concerns (NA if none) *
Student's Home Church, if applicable.
Your Student will be placed in a ‘Tribe’ for VBS.  Place my Student in any Tribe.
 *
Yes
No
Select one
If No, please try to place my Student with...Enter Name Below.  (We will try, but cannot guarantee placement.)
Parent or Guardian's Name *
Relationship to Student *
Parent
Other
Select one
Address *
Mobile Phone *
Email *
Emergency Contact Name. If same as above, answer Same. *
Emergency Contact Phone.  If same as above, answer Same. *
Emergency Contact's Relationship to Student. *
Parent
Other
Select one
How did you hear about this year’s VBS? *
Medical Release *
This consent gives permission to seek whatever medical attention is deemed necessary and releases the Church and its staff of any liability against personal losses of named child.

In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician.  In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.  I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider.  I agree to bring my child home at my own expense should he/she become ill or if deemed necessary by a WCC staff member.
Photo Release *
Pictures, videos or audio files from this or other Waushara Community Church (WCC) events may be captured and used for promotional purposes such as brochures, videos, web pages, or social media.  Please select the box which indicates your decision on a Photo Release for your child.
First and Last Name of Person Completing this Form, and current date. *
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