Child Name: (required)
Child Age: (3 yrs.-entering 6th grade) (required)
Child Birthdate: (required)
Mother and/or Father Name: (required)
Address Street and Number: (required)
City and Zip: (required)
Home Phone: (Mom)
Cell Phone: (Mom)
Home Phone: (Dad)
Cell Phone: (Dad)
Your Email: (required)
In case of emergency contact and/or alternate pick-up: (required)
Emergency Contact Phone: (required)
2nd Emergency Contact Name
2nd Emergency Contact Phone
Special Password for Pickup: (required)
Name of special friend(s) your child might like to be with:
Allergies or other medical conditions: (Snacks provided-PLEASE check with our kitchen for snack approval if your child has
allergies. You are welcome to provide an appropriate snack for safety).
Will your child have an Epi-Pen for an allergy?
If yes, a representative will administer the Epi Pen if the child cannot, while contacting 911/EMS and then immediately contacting the parent or emergency contact.
Home Church Name:
How did you hear about our VBS progam?
If Other, please specify where:
Those staff and volunteer representatives of Grace Lutheran Church will take every possible safety precaution and every possible attempt will be made to contact parents or emergency contacts immediately in the event of injury or emergency.
AGREEMENT/WAIVER AND RELEASE (must be agreed to below, in order to participate in VBS programs):
In consideration for being permitted by Grace Lutheran Church and its representatives to participate in the Vacation Bible School (VBS) program, I hereby waive, release and discharge any and all claims for damages for personal injury, death, or property damage which I may have or which may hereafter accrue to my child enrolled (as listed on page one of this registration form), as a result of participation in said activities. It is understood that these activities involve an element of risk of accidents, and knowing those risks, I hereby assume those risks. It is further agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns.
I hereby consent that my child enrolled at Grace Lutheran Church for VBS hereby execute the above AGREEMENT/WAIVER AND RELEASE on their behalf. I hereby agree to indemnify and hold the persons and entities mentioned above free and harmless from any loss, liability, damage, cost or expense which may incur as a result of the death or any injury or property damage that said minor may sustain while participating in VBS activities.
By checking here I certify that I am a parent of the above child and agree to this waiver and release: (required)
This waiver is to be signed by all participating adults 18 years old and over, and by a parent/guardian for
participants under age 18.
Includes daily snack/Bible Buddies/crafts and more: $15.00 per child
Cash or checks payable to Grace Lutheran Church
(Or go to our website's Donations page and pay using the "VBS Registration" option)
(office use): Date received:______________ Check#____________$______________Received by:____________