VBS Registration

Child Information

* Indicates required field

Child's Name: *

First

Last

Date of Birth *

Gender: *

Last School Grade Completed: *

Age: *

Parent/Guardian Name: *

Parent/Guardian Contact Number: *

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Home Church: *

Medical Information

Allergies or other medical conditions: *

In case of emergency, contact: *

Phone Number *

Relationship to child: *

Transportation

Will your child require van service to and from VBS? *

If "yes" for van service:

Contact Person: *

Insurance Company *

Policy Number *

Phone Number *

Address to be picked up: *

Line 1

Line 2

City

State

Zip Code

Country

Disclaimer for liability on riding the van:
I hereby give my consent that any necessary treatment may be given to my child by medical personnel in case of an accident or illness while at VBS, in town or in route to or from Shiloh Missionary Baptist Church of Russellville.

I understand that payments for medical care will be my responsibility. I also do hereby release Shiloh Missionary Baptist Church of Russellville or any of its agents from any claim of liability arising from their normal duties as sponsors on the trip.

Do you agree to the van disclaimer? *

Yes No

Disclaimer for media

I understand that as a Participant, I or my child may be photographed or videotaped during all VBS activities, and these photo/videos may be used for promotional purposes.

Do you agree to the disclaimer for media? *

Yes No

Submit Registration