Vacation Bible School

Registration

Parent/Guardian Info.

First Name

Last Name

Email

Phone Number

Child Info.

First Name

Last Name

Gender

Male

Female

Birthdate

What grade will the child go into in the fall?

Allergies

Other medical/physical needs we should know. (If none please add N/A.)

Emergency Contact

(Other than parent/guardian listed above)

First Name

Last Name

Phone Number

Is the emergency contact able to pick up your child(red)?

Yes

No

Media Release

I agree to grant to Calvary Chapel Santa Clarita permission to record video and/or pictures of my participation. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications.

I grant permission for the above Media Release

Yes

No

Medical Release

Acknowledgement of Risk

I/we do hereby state I have legal custody of the aforementioned minor(s). I/we grant authorization and consent to Calvary Chapel Santa Clarita to administer general first aid treatment for any minor injuries or illnesses experienced by the minor(s). If the injury or illness is life threatening or in need of emergency treatment, I/we authorize Calvary Chapel Santa Clarita to summon any and all professional emergency personnel to attend, transport, and treat the minor(s), understanding my insurance is primary, unless otherwise indicated.*

Acknowledgement & Certification

I have read and understand the above Medical Release Waiver. I certify that the information provided is accurate and complete. I also confirm that the participant is physically fit to take part in VBS activities, or that any pertinent medical conditions have been disclosed on the registration form.

By signing below, I indicate my understanding and acceptance of the terms set forth in this document.

First Name

Last Name

Today's Date

Signature