VBS - Miracle Center

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Event Timing: June 21-23, 2023 (Wed. - Fri.)

6PM - 8PM Nightly (Transportation Available)
Event Address: The Anchor Church 1029 W County Rd 600 N, Brazil IN 47834
Contact us at (812) 531-0408 or apostolicsofbrazil@gmail.com

Email *

VBS Registration Form

Registration must be filled in by parent or guardian

Child's Name (First & Last) *

Gender *

Male

Female

Child's Age *

Birth-date *

YYYY

Last Grade Completed *

Transportation Needed *

I give permission for my child to ride the Anchor Church Bus

Yes

I give permission for my child’s photo to be taken for publicity use for the church’s social media *

Yes

Parent/Guardian Name *

Home Address (Street, City, State, Zip *

Phone Number *

Home Church if Applicable

If neither parent/guardian listed above is available in an emergency, please contact:

Name, Relationship to Child & Phone Number *

CHILD MEDICAL INFORMATION

Medications (such as an EpiPen or inhaler) that will accompany child (all medications must be clearly marked with the child’s name and dosage)

Allergies or Other Medical Conditions of your child (including medication allergies in case of an emergency)

LIABILITY WAIVER

By signing this form, We, the parent(s) / guardian(s) of the child listed above, will not hold The Anchor Church, its members or affiliated staff, responsible or liable for any accident that may occur while our child is at VBS 2023.

Parent or Guardian Signature (Digital) *

PARENT/GUARDIAN MEDICAL AUTHORIZATION

In case of an accident or incident, I give my permission for Church authorities to seek medical care, use of a physician or hospitalization or surgery for the child listed above. I understand in the event that an emergency would arise that requires medical attention, I will be notified immediately. However, should Church authorities be unable to locate or not have time to contact the child’s parent, guardian, or emergency contact, they may take such temporary measures as they deem appropriate and necessary. Also, I grant permission for routine nonsurgical medical care for the above named child. I hereby authorize the release of pertinent medical/dental information to insurance companies and I hereby authorize the insurance benefits be paid directly to the provider of medical/dental services.

Parent or Guardian Signature (Digital) *

PARENT/GUARDIAN AUTHORIZATION

The above named child has my permission as parent or guardian to attend the 2023 VBS Miracle Center hosted by The Anchor Church located in Brazil, Indiana

Parent or Guardian Signature (Digital) *

Additional Comments

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

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