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Oakhurst Evangelical Free Church and Oakhurst First Baptist Church
VBS 2019
REGISTRATION FORM
VBS 2019 Registration
Parent/Guardian Name
*
Email
*
Day Phone
*
Cell Phone
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Church
Number of Children being Registered
*
Please enter a value between
1
and
5
.
Child(ren) Information
Name
*
Nickname
Birthdate
*
Grade entering in Fall 2019
*
Gender
*
Male
Female
Name
Nickname
Birthdate
Grade entering in Fall 2019
Gender
Male
Female
Name
Nickname
Birthdate
Grade entering in Fall 2019
Gender
Male
Female
Name
Nickname
Birthdate
Grade entering in Fall 2019
Gender
Male
Female
Name
Nickname
Birthdate
Grade entering in Fall 2019
Gender
Male
Female
Emergency Contact
In case of an emergency and the parent or guardian cannot be reached, who would be contacted?
Primary Contact Name
*
Relationship to Child
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Secondary Contact Name
Relationship to Child
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Medical Information
Childs Physician
Physicians Phone Number
Medical Insurance Carrier
Policy #
Please list any: Medical Conditions, Activity Restrictions, Drug/Food/Other Allergies:
Acceptance and Comments
Legal Stuff
LIABILITY RELEASE: This event is co-sponsored by Oakhurst Evangelical Free Church and Oakhurst First Baptist Church (referred to as "the Church" in these releases). I hereby release "the Church" and the above mentioned VBS Program and/or VBS leaders/Volunteers from liability in case of injury or illness to the above named Child(ren). The above named child(ren) has my permission to participate in the activities in the above named VBS Program. If I cannot be reached in the event of an emergency, I give permission for necessary medical care, to secure proper treatment and to order injections, anesthesia or surgery for the above named child(ren). I understand that all charges for service not billed to my insurance carrier will be billed to me as parent/guardian.
Medical Authorization
MEDICAL AUTHORIZATION: By checking acceptance below and SIGNING REGISTRATION the first day I hereby give permission to "the Church" Vacation Bible School staff/volunteers to secure any medical treatment that may become necessary. I acknowledge that Participant has my permission to fully participate in activities, except as otherwise noted on this registration form.
Photo Release
PHOTO RELEASE: I hereby grant to "the Church" and to its employees, agents and assigns the right to photograph me or my dependent and to use the photo and or other digital reproduction of him/her to other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital, or electronic publishing via the internet.
*
I understand and agree to the above terms of VBS participation.
Parent/Guardian Signature (First Day of VBS)
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