VBS Student Registration

Student Registration for 2010 Vacation Bible School

July 12 - July 16, 2010

9 am - 12 noon -- there will be one session and it is in the morning only this year.

Children 3 years (potty trained) through

12 years (completed 6^th Grade)

Student’s Full Name:

Parent/Guardian Name:

Student's Birthdate: Student’s Age: Grade Completed:

Street Address: City, State, ZIP:

Parent's email:

Phone Number:

Religious Affiliation: Home Church:

How did you hear about VBS:

Authorized pick-up person:

Emergency Contact Person:

Emergency Phone:

Doctor's Name:

Doctor's Phone:

Shots up to date:

Date last tetanus shot:

List any unusual health conditions (allergies to food, shots, etc.):

...

Parents - Please read! By Clicking "Register Now!" you agree to the following:

I hereby agree to allow my child to participate in the programs and activities of Vacation Bible School. I do hereby release and hold harmless St. Paul’s Moravian Church and its representatives from any and all liabilities arising from any injuries that might occur during the supervised programs and activities. Further, I give permission for Medical Personnel to administer First Aid and/or medical treatment in case of emergency and to refer the patient to a local clinic or hospital for treatment if necessary.

July 12 - July 16, 2010

Children 3 years (potty trained) through

12 years (completed 6th Grade)

12 years (completed 6^th Grade)