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Church Renovation Before
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2016 Spring Picnic
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2nd Annual Cool Weather Picnic
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Home
About Us
What We Believe
Our Staff
Our Gatherings
Our Ministries
>
Children
Teen
College
International
Senior
Music
Spanish Speaking
Our Supported Missions
Events Calendar
Photo Gallery
Church Renovation Before
Renovation After
2016 Spring Picnic
2016 VBS
2nd Annual Cool Weather Picnic
Media
Contact
Child Information
*
Indicates required field
Child's Name:
*
First
Last
Date of Birth
*
Gender:
*
Select One
Male
Female
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?
*
Select one
Yes
No
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