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 VBS Registration Form
  

 

SonSurf Beach Blast VBS

Registration Form

August 6-10, 2012

MAIL COMPLETED FORMS TO: St. Luke’s Episcopal Church

500 Hillcrest Blvd Phillipsburg, NJ  08865

908-859-1479

 

Child 1 Information  (must be 4 as of 9/30/12)


Child’s Name_______________________________________________ Gender: male or female

Grade Entering Fall 2012: _____________________________Date of Birth: ________________

Any Allergies or other Medical concerns: ____________________________________________

 

Child 2 Information  (must be 4 as of 9/30/12)


Child’s Name_______________________________________________ Gender: male or female

Grade Entering Fall 2012: _____________________________Date of Birth: ________________

Any Allergies or other Medical concerns: ____________________________________________

 

Parent or Guardian’s Information

Name: ____________________________________________ Relation to child:_____________

Address: ______________________________________________________________________

City: _______________________________________ State: ___________ Zip Code: _________

Home Phone: ____________________________ Cell Phone: ____________________________

Work Phone: _____________________________ Email: ________________________________

Home Church, if any:_____________________________________________________________

 

Emergency Contacts (please list any other people who may pick up child)

Name: _____________________________________________ Relation to child:_____________

Home Phone: ____________________________ Cell Phone: ____________________________

Name: _____________________________________________ Relation to child:_____________

Home Phone: ____________________________ Cell Phone: ____________________________

 

Medical Information

Name of Family Pediatrician: ______________________________________________________

Address: ______________________________________________________________________

Phone Number: ________________________________

Insurance Carrier: ______________________________Policy Id__________________________

 

Food Allergy Policy

In many ministries and programs at St. Luke’s, food is often a key component.  While we try to be as sensitive as possible to persons with food allergies, volunteers often prepare and serve food that may inadvertently contain ingredients that could cause allergic reactions.  For children, parents must be responsible for determining if their child can participate in the preparation or consumption of the foods offered.  If your child has a severe or life-threatening food allergy, you have the option of helping prepare the snack and staying with your child during snack time, or sending a separate snack with your child each day.  Please tell us what you decide.

 

Waiver

As the parents or guardians of this(these) child(ren), I authorize participation in St. Luke’s VBS.  I assume all risks and hazards incidental to such participation both during an activity and en route and do herby release and waive all claims against St. Luke’s Church, its staff, volunteers, and participants.  I understand the Food Allergy Policy outlined above.  I also grant permission for emergency first aid to be given to my child(ren) in case of injury and transportation to the hospital, if necessary.

Parent’s Signature: _______________________________________________Date: __________

 

Permission to Photograph or Videotape

During VBS activities, we may use your child(ren)’s photograph or video image for public viewing and in promotional materials for this church, including the church website and newsletter.  If you do not wish to have your child’s image appear in such publications as a photograph, website, or a video, you must notify the church in writing by August 1, 2012.  It is assumed that parents and guardians consent to their child(ren) being photographed, videotaped, or having their image so used unless such notification is received by St. Luke’s before the date above.

 


Creation date: Jun 5, 2012 6:30 am     Last modified date: Jun 5, 2012 7:21 pm   Last visit date: Dec 9, 2016 1:36 pm     link & embed ?...
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