Vacation Bible Camp Registration Form

VBC is July 9-13 from 9:00am-12:30pm

For Children entering Grades K-6 in the Fall of 2018
(Children must be age five by September 1st to enter the Kindergarten class)

Child's Information

Child's Name *

First Name Last Name

Birth Date *

Month Day Year

Grade *

in Fall 2018

Gender *

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian Information

Name *

First Name Last Name

2nd Parent/Guardian's Name

First Name Last Name

Cell Number *

- Area Code Phone Number

Home Number

- Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship

Phone Number *

- Area Code Phone Number

Alt. Phone Number

- Area Code Phone Number

Who is allowed to pick up your child?

Parent 1 Parent 2 Emergency Contact

Medical Insurance Name, Group & Policy Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler or other emergency medical device? If yes, please explain any instructions.

Permission, waiver & release.

In consideration for the opportunity to participate in Brush Prairie Baptist Church Vacation Bible Camp, the undersigned parent/guardian of the participant acknowledges that the participant is physically and mentally able to participate, and further acknowledges and accepts the risks of injury associated with participation. The undersigned parent/guardian accepts personal financial responsibility for any injury sustained during participation. Further, the undersigned parent/guardian promises to indemnify, defend, and hold harmless Brush Prairie Baptist Church, its agents, employees, and representatives against any claim or liability arising as a result of such participation, whether such claim arises out of the negligence of Brush Prairie Baptist Church or otherwise. The undersigned parent/guardian warrants that the participant has medical insurance and is under the supervision of church sponsors who are authorized to arrange for such medical and hospital treatment as deemed advisable for the health and well being of the participant. The undersigned parent/guardian understands that the participant’s personal medical insurance is primary. The undersigned parent/guardian gives permission for photos of the participant to be taken, and to be presented in various church-sponsored media including, but not limited to: photos, videos, slide presentations, newsletters, bulletins, brochures, programs, and Internet web pages.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.