Breaker Rock Beach VBS 2024 Registration
What:         Breaker Rock Beach VBS
Date:          Mon, June 24 - Fri, June 28
Time:          6:00pm - 8:30pm 
Location:   Fairfield Christian Church
                 1965 N Columbus Street
                    Lancaster
                 
Ages:         Ages 4* through 5th Grade

*Preschoolers must be FULLY potty-trained

NOTE: You will need to complete this registration form for EACH child you are registering. 

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Email *
Child's First and Last Name: *
Age: *
Date of Birth: *
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Gender: *
Grade Entering in the Fall: *
For younger children only - is your child fully potty-trained? 

(Note that independence in the restroom is required)
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Name(s) of Parents/Legal Guardian: *
Street Address: *
City: *
State: *
Zip: *
Parent/Guardian's phone number during VBS: *
Allergies/Medical Conditions/Special Needs: 
Generally speaking, kids will be grouped all week by grade. If your child would prefer to be paired with a friend who is in a different grade, please enter their name here and we will do our best to accommodate your request. 

(Note - typically we will put the older child with the younger child.)

(Note - we are unable to accommodate grouping kids together who have a significant age difference.)
Please list the names of ALL persons who have permission to pick up your child from VBS (INCLUDING PARENTS) *
Is there anyone who is NOT permitted access to your child at VBS? If so, please list name:
Emergency Contact Name: *
Emergency Contact Phone Number *
Do you regularly attend church?
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If yes, where?
How did you hear about Breaker Rock Beach VBS?
Notes/Comments:
Photo Release

I give permission for my child to be photographed and videotaped for use in any and all internal or public Fairfield Christian Church publications, including (but not limited to): video and other media presentations, bulletin boards, printed materials, church website, church social media, etc. 
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Required
Liability Release

We (I), being 18 years of age or older, (myself) (and for and on the behalf of my child-participant if said child is not 18 years of age or older) do hereby release, forever discharge and agree to hold harmless Fairfield Christian Church and the KidsQuest Program thereof from any and all loss, liability, claims or demands of any nature whatsoever which may be incurred by the undersigned and the child participant that occur while said child is participating in any and all trips and/or activities. Further, authorization and permission is hereby given to Fairfield Christian Church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree to hold harmless and indemnify Fairfield Christian Church, and the KidsQuest Program for any liability sustained by Fairfield Christian Church as the result of negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. If the participant has not attained the age of 18 years: we (I) are the parent(s)/legal guardian(s), with legal custody of this participant, and hereby grant our (my) permission for him (her) to participate fully in said activity, and hereby give permission to take said participant to a doctor, hospital or emergency treatment center, and hereby authorize medical treatment, including but not in limitation to   emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

By electronically signing below, we (I) attest to be the custodial parent(s)/legal guardian(s) of the participant above.

(Enter full name below)

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Consent to Medical Treatment

We (I), the parent(s)/legal guardian(s), with legal custody of the above named minor, understand that in the event medical treatment is required every effort will be made to contact me. However, if we (I) cannot be reached, we (I) give permission to Fairfield Christian Church to take said participant to a doctor, hospital or emergency treatment center to obtain treatment. We (I) consent to any  X-rays, examinations, anesthesia, medical or surgical diagnosis, treatment or hospital care deemed necessary, in the event that I can not be reached.

By electronically signing below, we (I) attest to be the custodial parent(s)/legal guardian(s) of the participant above.

(Enter full name below)

 

 *
COVID-19 Liability Waiver, Release and Assumption of Risks

We(I) acknowledge the highly contagious nature of the Coronavirus/COVID-19 and acknowledge that the CDC and many other public health authorities recommend practicing social distancing and wearing a mask.  We(I) agree to comply with all COVID-19 policies and procedures to reduce the spread of the virus while attending Fairfield Christian Church KidsQuest.

I further acknowledge that Fairfield Christian Church and its KidsQuest Program have put in place preventative measures to reduce the spread of COVID-19, but understand that there are known risks associated with placing my child in the group setting at KidsQuest that I must assess. 

By placing my child in the care of KidsQuest, I voluntarily assume the risks of my child, myself, or my family members contracting COVID-19, and any costs or damages incurred as a result.

Further, I release and agree to hold Fairfield Christian Church and the KidsQuest program harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all bodily injury, illness, death or medical treatment, that may arise from, or in connection to, any participation with Fairfield Christian Church KidsQuest, caused by negligence or otherwise. This liability waiver and release extends to Fairfield Christian Church, its leaders, employees, and volunteers.

By electronically signing below, we (I) attest to be the custodial parent(s)/legal guardian(s) of the participant above.

(Enter full name below)

 

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A copy of your responses will be emailed to the address you provided.
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