2019 VBS Registration Form

Rolling River Rampage VBS 2019

* Indicates required field

Child's Name *

First

Last

Parent/Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Cell Phone *

Date of Birth *

Current Age *

Parent Email *

Last School Grade Completed *

Home Church *

Do you want your child to stay for the free lunch each day at noon? *

Photography Permission: I give Peace Presbyterian Church permission to photograph my child. Photos may be used in the building or on the website. *

Yes No

I (we), the undersigned parent(s) or guardian(s) of

Name *

First

Last

A minor, do herby authorized adult volunteers of Peace Presbyterian Church Vacation Bible School as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by an accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability Peace Presbyterian Church any of its minister or leaders in the event of an accident en route, during and returning from the above-mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence. The following persons have permission to pick-up my child.

Name of Person Picking Up *

First

Last

Parent/Legal Guardian *

First

Last

Parent/Legal Guardian Signature *

Date *

Emergency Phone *

If Parent/Legal Guardian is unavailable in an emergency, please contact

Name *

First

Last

Phone Number *

Name *

First

Last

Phone Number *

Please List any allergies or medications. Include food, seasonal, etc.

Comment *

Submit

Thank you for registering your child for VBS! Please fill out one form per child. If you need a paper copy of this form, please call or visit Peace Presbyterian Church at 910.488.3211 or 3203 Ramsey Street!
VBS Starts Monday, July 15 at 9:00 a.m.