2019 Trinity Folsom VBS Registration Form

Vacation Bible School 2019 ~ Registration Form

July 22nd - 26th, Monday to Friday, 9:00-12:00

Parish Hall, Trinity Episcopal Church

801 Figueroa Street, Folsom, CA 95630

916-985-2495

For any questions, email Karen Van Winkle or Fr. Charlie.
Child #1*

First NameLast Name
Grade in Fall 2019*
Birthdate*
Age*
Gender

FemaleMale
Child #2

First NameLast Name
Grade in Fall 2019
Birthdate
Age
Gender

FemaleMale
Child #3

First NameLast Name
Grade in Fall 2019
Birthdate
Age
Gender

FemaleMale
Child #4

First NameLast Name
Grade in Fall 2019
Birthdate
Age
Gender

FemaleMale
Child #5

First NameLast Name
Grade in Fall 2019
Birthdate
Age
Gender

FemaleMale
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which days will they be participating?

All daysMonday, July 22Tuesday, July 23Wednesday, July 24Thursday, July 25Friday, July 26
Parent/Guardian Information
E-mail*
Name 1*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Name 2

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
The following people are authorized to pick up my child(ren) (in addition to those listed above)
Interested in Supporting?

I'd like to volunteer!I'd like to donate supplies, snacks, etc!
Allergies, Medical Needs, Anything else we should know!

Please bear in mind that we will not be able to administer any medication.
Insurance Provider*
Insurance Policy Number*
Allergies/Dietary Restrictions
Additional information (e.g. sensitivity to loud noises or a tendency to wander off).
Permission and Liability Waiver

In order for your child(ren) to participate, you must complete, electronically sign, and submit the following statement of consent / liability waiver and medical release. As parent or legal guardian, you remain fully responsible for the actions of your child.

I hereby consent to participation by child(ren), a minor, in Vacation Bible School 2019 at Trinity Episcopal Church, Folsom, CA.

In consideration of my child(ren) being allowed to participate in VBS, I hereby agree on behalf of myself and my child(ren), to release Trinity Folsom, the Episcopal Diocese of Northern California and any and all affiliated organizations, their employees, agents and representatives, (collectively “Releases”) from any and all claims, including negligence, which may be asserted by me or my child(ren), or on behalf of my child(ren), arising from or relating to my child(ren)'s participation in the program. In the event this release on behalf of myself and/or my child(ren) is held to be invalid or unenforceable, I hereby agree to indemnify and hold harmless Releases from any and all claims, including negligence, which may be asserted by me or my child(ren), or on behalf of my child(ren), arising from or relating to my child(ren)’s participation in this program. This release or indemnification does not apply to claims for intentional misconduct or gross negligence; nor does this release or indemnification apply to the extent of commercial insurance coverage for any claim, but this Release or Indemnification shall apply to the extent of any self- insurance or deductible applicable to any claim.
Permission and Liability Waiver Consent*

I give my consent
Medical Release

I/we, the parent(s) or legal guardian(s) of the above named child(ren), a minor, hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed medical personnel on staff of any licensed hospital. This authorization is given in advance of any specific diagnosis, treatment, or hospital care required, but is given to provide authority and power to render care, which is deemed advisable in the best judgment of the physician.
Medical Release Consent*

I give my consentI do not give my consent
Photo Release

I give Trinity Episcopal Church permission to take photographs of my child(ren), a minor, and to use those images and recordings in church publications only (including social media). Trinity will not tag or otherwise identify individual children by name in photographs or posts.
Photo and Audio Release*

I agreeI do not agree
Parent/Guardian Signature*
Should be Empty:

Parent/Guardian Information

Allergies, Medical Needs, Anything else we should know!

Permission and Liability Waiver

Medical Release