VBS Registration Form

Registration Type*

Crew/Student Grades PreK-4
Crew Leader Grades 5 and up

Current Grade*

Child's Name*

First Last

Date of Birth*

Parents Name*

First Last

Address*

Street Address Address Line 2 City ZIP / Postal Code

Cell Phone #

Home Phone #

Which number to call first*

Cell
Home

Email

Parish

Emergency Contact while your child is with us*

First Last

Emergency Contact Phone*

Family Doctor*

Family Doctor's Phone Number*

Allergies/Medications/Conditions*

Any food allergies?*

Names of people who will be picking up your child other than you:

Photo/Video Release*

Photo's and/or video's of minors may be taken for use in parish publications. In checking "I agree" you are acknowledging this and granting permission to Immaculate Conception Faith Formation to use photo's and video's of your child and his/her name in publications and displays.

I agree
I DO NOT agree

Parent's Name - Medical/Liability Release*

MEDICAL/LIABILITY RELEASE VALID APRIL 25-29,2016 In the event of sickness or some medical emergency, I request that my child receive any medical attention or treatment deemed necessary. therefore I give permission to any hospital, doctor, and/or health care provider to transport and/or admit for care of my child. I understand that I am responsible for all expenses and charges for the treatment and care of my child. In the event that I am not present at the time of emergency or cannot be contacted, my childs care has been entrusted to the staff and designated ministry leadership of Immaculate Conception.

Date*

Any comments or other information you think we should know about.