Registration

Name of Parent(s):

Email Address:

Address:

City:

State: Zip:

Home Phone: Cell Phone:

Please list emergency contacts:

Name: Phone:
Relationship:

Name: Phone:
Relationship:

Please list only the children attending VBS:

Child 1: Age: Grade:

Allergies or other medical conditions:

Child 2: Age: Grade:

Allergies or other medical conditions:

Child 3: Age: Grade:

Allergies or other medical conditions:

Child 4: Age: Grade:

Allergies or other medical conditions:

Medical and Liability Release:

Medical Release: If my child should become ill or injured at Church of Jesus Christ Spirit Filled, I understand that the facility will (1) call 911 should the problem be deemed an emergency and (2) contact me immediately or designated emergency contact. Should the facility be unable to reach me or the emergency contact person, they are authorized to contact my child’s physician and/or arrange for immediate emergency treatment. I will accept full responsibility for payment of all medical services rendered. I do herby release, forever discharge and agree to hold harmless Church of Jesus Christ Spirit Filled and its directors thereof from any liability, claims or demands for personal injury, sickness or death, as well as property damage or expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the Summer Programs of Church of Jesus Christ Spirit Filled. The undersigned further hereby agrees to hold harmless and indemnify said church, it’s directors, employees and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto. The undersigned further consents to the administration of first aid and or doctor’s care, or any form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as hereto described, the undersigned agrees to hold harmless and indemnify said church, it’s directors, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.

Check this box if you agree to the terms of the Medical and Liability Release.

To prevent spam, please answer the question.

2+6=?