* Child's Name:

* Gender:
Select OneMaleFemale

* Birthdate MM/DD/YYYY:

* Age (on the first day of VBS):

* Last Grade Completed:
Select OneNonePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6

Are you bringing a guest? Name of guest. (Guest must be registered separately.):

Allergies / Health Conditions / Medications:

Other Helpful Info (Special needs, restrictions, etc.):

* Name of Parent(s) / Guardian(s):

Church Affiliation:

* Postal Address:

* City:

* State:

* Zip:

Email Address:

* Phone 1:

Phone 2:

* How did you first hear about our VBS program?
Select OneChurchFriend / RelativePoster / FlierRoad SignWebsiteOther

* Emergency Contact Name:

* Emergency Contact Phone:

If you NEED your child to be with a specific friend, that must be set-up during this registration process, before room assignments are made, NOT on the first day of VBS. Please enter one name here if this is a need. (Friend must register separately.):

2013 VBS LIABILITY RELEASE AND PHOTOGRAPHY / VIDEO AUTHORIZATION
In the event of an emergency, I understand that all will be done to contact me or the emergency contact named above. However, if neither can be reached, I give full permission to a representative of Westminster Presbyterian Church to seek medical attention in my absence for the child registered on this form.

I also hereby assume all risk, known or unknown, for the child registered on this form, in connection with their attendance and participation in Vacation Bible School at Westminster Presbyterian Church. I acknowledge that participation in Vacation Bible School at Westminster Presbyterian Church is voluntary and therefore I FULLY RELEASE and discharge Westminster Presbyterian Church, its pastors, employees, directors, and volunteer workers, from any and all liability in connection with any activities carried on at Westminster Presbyterian Church in the Vacation Bible School program.

I further acknowledge that any child registered on this form, as a participant in Vacation Bible School at Westminster Presbyterian Church, may be photographed or captured on video during the Vacation Bible School program and activities. I hereby grant full permission to Westminster Presbyterian Church to use photographs or videos-in print, electronic, online, or other public media-of the child registered on this form and further release Westminster Presbyterian Church from any and all liability connected with the authorized use of words and image of the child registered on this form.

Liability:

I agree to the above Liability Release and Photography/Video Authorization

* Name of Adult filling out this form.