Jamestown Reformed Church VBS Registration

Child Name

Parent(s) Name

Grade Entering

Preschool/Pre-K Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

This address will receive a confirmation email

Phone

Address

Gender

Male Female

Allergies or Medical Information

Home Church

At dismissal my child may:

Release my child only to an approved adult listed below (Child will remain with teacher in Sanctuary until approved adult comes and picks them up) Excuse child – no adult required for pick up (Child excused from Sanctuary to find their parent)

My child may be picked up by the following person(s)

Secondary Emergency Contact

Emergency Contact Number(s)

Family Doctor

Family Doctor Phone Number

Preferred Hospital

Liability & Medical Waiver: I, for myself, my minor child(ren) and for my child(ren)’s other parent and/or guardian, understand that all reasonable safety precautions will be taken at all times by Jamestown Reformed Church and its agents during onsite and offsite events and activities as well as when transporting my child(ren). I understand the possibility of unforeseen hazards and know the inherent possibility of risk. In signing this form, I agree not to hold Jamestown Reformed Church, its leaders, employees, and volunteer staff liable for damages, losses, or injuries incurred by the subject of this form. In case of a medical emergency, I understand that every effort will be made to contact myself, the parent/guardian of the child, listed on this form. In the event I cannot be reached, I hereby grant permission to the physicians selected by Jamestown Reformed Church to hospitalize secure proper treatment for and/or order injection, anesthesia or surgery for my child(ren) listed on this form. Photo Release: I give permission for the photo and video of my child(ren), which may be taken during any ministry activity, to be used for publication purposes and/or to appear on the church websites, social media or other in-house publicity.

Jamestown Reformed Church VBS Registration

Description

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