Time Lab Registration Form, VBS 2019

Time Lab Registration Form, VBS 2019

Please fill in the form below.
CHILD/REN INFORMATION
Child/ren's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CHILD NO. 1

First NameMiddle NameLast Name
Age
Special Needs/Allergies?
CHILD NO. 2

First NameMiddle NameLast Name
Age
Special Needs/Allergies?
CHILD NO. 3

First NameMiddle NameLast Name
Age
Special Needs/Allergies?
CHILD NO. 4

First NameMiddle NameLast Name
Age
Special Needs/Allergies?
CHILD NO. 5

First NameMiddle NameLast Name
Age
Special Needs/Allergies?
PARENT/GUARDIAN INFORMATION
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOTHER

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
FATHER

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
GUARDIAN

First NameLast Name
Phone Number

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

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to child/ren*
NAME*

First NameLast Name
Phone Number*

Area CodePhone 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 permissionI 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 NameLast Name
Date*

MonthDayYear
Date
Should be Empty: