Plum Creek PC VBS Registration

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Child's Name *

Home Address *

City *

Zip Code *

Birthdate *

YYYY

Age as of July 2019 *

Grade from 2018/2019 School Year *

Home Church *

Does your child have any allergies or other pertinent health information? *

Is there any other information, such as custody arrangements, special needs, or physical limitations that we should know about your child in order to ensure they have a safe and exciting time at VBS? *

Name of Parent/Guardian for Primary Contact *

Best Phone # to contact during VBS hours *

Alternate Phone # to contact

Email address *

Name of Parent/Guardian for Secondary Contact *

Best Phone # to contact during VBS hours *

Alternate Phone # to contact

In the case of an emergency where neither parent/guardian can be reached, what is the name of the person who should be notified? *

Relationship to child *

Phone Number *

I would like more information about volunteering at Vacation Bible School.

Conditions of Registration

I approve the information above and the conditions listed below. I have written any necessary information concerning our family and our child.
● I hereby give my permission for my child to participate in Vacation Bible School at The Presbyterian Church of Plum Creek. I understand and am aware of the risks involved in these activities. I hereby release The Presbyterian Church of Plum Creek and its appointed leaders and agents from all liability, whether in negligence or otherwise, both for myself and my child.
● In case of Emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give The Presbyterian Church of Plum Creek permission to act on my behalf in seeking emergency treatment for my child, in the event that such treatment is deemed necessary by the program director. I give permission for those administering emergency treatment to do so, using those measures deemed necessary.
● I hereby give my permission for my child to have his/her photo/video taken. I understand photos may be used on the website, social media, or displayed in public places. I hereby release The Presbyterian Church of Plum Creek and its appointed leaders and agents from all liability, and give permission for my child to be photographed/videoed.
● If I have concerns, I know I can contact the program director, Faith Bailey at faith.plumcreek@gmail.com, to discuss them.
● I am registering my child for full participation in Vacation Bible School, July 1-3, 2019 from 9:30AM to 11:30AM.

By entering my name below, I certify that the information on this registration is correct to the best of my knowledge and that I have read and understand the "Conditions of Registration." *

Date *

YYYY

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