VBS

Vacation Bible School registration form
July 29–August 2, 2019

* Indicates required field

Parent/Guardian Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Email *

Are you a member of the church? *

Yes No

First Participating Child *

First

Last

Age *

Date of Birth *

Grade Entering *

Allergies/Medications/Special Needs? *

Second Participating Child *

First

Last

Age *

Date of Birth *

Grade Entering *

Allergies/Medications/Special Needs? *

Third Participating Child *

First

Last

Age *

Date of Birth *

Grade Entering *

Allergies/Medications/Special Needs? *

Fourth Participating Child *

First

Last

Age *

Date of Birth *

Grade Entering *

Allergies/Medications/Special Needs? *

Doctors Name & Phone Number *

Insurance Company, Group/Policy Number *

Emergency Contact Name/Phone/Relationship *

Release of Liability
The undersigned authorizes an adult, in whose care the minor has been entrusted, to consent to any x-ray, anesthetic, medical, surgical or dental diagnosis and/or treatment to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Christ the King Lutheran Church.

I have read, understood, and consent to all parts of the Health/Emergency & Release of Liability Form and hereby remise, release and forever discharge Christ the King Lutheran Church, its agents, members, employees, volunteers, servants, and all other persons, firms and corporations whosoever of and from any and all actions, claims, and demands, whosoever which claimant now has or may hereafter have on account of or arising out of any accident, casualty, and/or event which might happen while under the direction of the Christ the King Lutheran Church. I further understand that there is no Worker’s Compensation or Accident Insurance furnished by Christ the King Lutheran Church.

Name *

First

Last

Photo Release
I give permission for Christ the King Lutheran Church to photograph myself or my child while participating in activities of Christ the King Lutheran Church. I understand that these photographs may be included, but are not limited to: newsletters, posters, websites, social media, videos, and media releases.

Please check one of the options *

Yes, I agree with the conditions stated in the Release of Liability Consent Form No, I request additional information before registration is completed. Please contact Sarah Felde (317-627-1707) with questions.

Name *

First

Last

Submit

VBS 2019

Vacation Bible School registration formJuly 29–August 2, 2019

Vacation Bible School registration form
July 29–August 2, 2019