Time Lab Registration Form, VBS 2019

Child/ren's Address

Address *

MOTHER

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
FATHER

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
GUARDIAN

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
EMERGENCY CONTACT INFORMATION
NAME *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to child/ren *
NAME *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to child/ren *
PERMISSIONS
I give permission to Evangelical Presbyterian Church of Elkton (EPCE) to use my child's likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of EPC Elkton. AND I agree that EPC Elkton has all rights to images, audio, and video recordings for perpetuity.
*

I give permission I do not give permission
In case of emergency, should EPCE staff be unable to immediately contact the parent or guardian of the registering child, I give EPCE permission to seek and obtain medical attention, treatment and services as deemed necessary by EPCE staff. AND I agree to assume responsibility for all medical costs incurred.
*

I give permission
SIGNATURE
* Entering your name serves as a valid signature.
Name *

First Name Last Name
Date *

Month Day Year
Date Date Picker Icon
Should be Empty: