Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (During VBS time) *

(###)

###

####

Home Phone

(###)

###

####

Permission to seek medical care/Liability waiver *

I give permission to the staff to seek medical attention if necessary while participating in any of our functions. I understand that all necessary precautions will be provided to my child (children) for their safety. I will not hold the church, its staff, or volunteers/helpers liable.

I give permission for my child to be photographed or video'd for lawful VBS use only (optional)

Yes my child can be video'd or photographed for VBS use

Date *

MM

DD

YYYY

Selecting this box acts as my signature *

I am signing my name