2017 VBS registration
2017 VBS REGISTRATION
St. Paul Lutheran Church & School June 19-23
CHILD 1
Name: _________________________ Age: _______
Last Grade Completed in School: ________________________ T-Shirt Size (Circle One):! XS(2-4)
S(6-8)
M(10-12)
L(14-16)
XL(18-20)
Medical or Other Information or Allergies (please send a snack for child with food allergies): _____________________________________________________________________________________
CHILD 2
Name: _____________________________Age: ___________
Last Grade Completed in School: __________________________________ T-Shirt Size (Circle One):! XS(2-4)
S(6-8)
M(10-12)
L(14-16)
XL(18-20)
Medical or Other Information or Allergies (please send a snack for child with food allergies): _____________________________________________________________________________________ Would you like your child(ren) to be placed in a group with another specific child? (We will do our best to honor requests.) _____________________________________________________________________________________ If your children's ages fall within the same grouping, would you prefer your children to be: placed in the same VBS group or separated into different VBS groups?
Parent/Guardian Name(s): _____________________________________
Phone 1: ______________________________
Email: _______________________________________
Phone 2: ______________________________
Address: ______________________________________________________________________________
Emergency Contacts Name & Phone: _____________________________________________ Name & Phone: _____________________________________________ Church Home: ________________________________________________________________________ Will your child(ren) be attending child care from 7-9 am? (There is no charge for the week of VBS): Y
N
PARENT PERMISSIONS: If you would like your child(ren) to participate in bounce house & all VBS activities, please sign the following statement of consent and release of liability. As a parent or legal guardian, you remain fully responsible for the actions and conduct of your child(ren), including any legal responsibility which may result. I hereby consent to participation by my child(ren) (named above) in this activity. I understand that this event will take place at the church facilities and that my child(ren) will be under supervision on the stated dates. I further consent to the conditions stated above regarding participation in this event. In consideration of my child's being allowed to participate in this activity, I agree to indemnify and hold harmless St. Paul Lutheran Church & School and its representatives, including chaperones, from any and all claims, including negligence, arising from or relating to my child's participation in this event. This indemnification and hold-harmless agreement does not apply to claims for intentional misconduct or gross negligence. VBS leaders have permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with this VBS program.
Parent/Guardian Signature: ________________________________________ Date: __________________
Hike cloud-shrouded ruins of Machu Picchu. Savor exotic flavors of the Amazon. Hear what daily life is like from kids in Peru.
Grab your passport for an unforgettable VBS trek where kids discover God’s good gifts for us all.
vacation bible school
June 19-23 Age
s 3 (& p otty trained !) throu gh 5th gra de. Register on the back of this form or online at
www.stpaulroseburg.org 9:00 am - 12:00 pm
free child care offered the week of VBS 7:00 - 9:00 am St. Paul Lutheran Church & School 750 W Keady Ct. | Roseburg, OR 97470 541-673-7212
St. Paul Lutheran Church & School June 19-23
CHILD 1
Name: _________________________ Age: _______
Last Grade Completed in School: ________________________ T-Shirt Size (Circle One):! XS(2-4)
S(6-8)
M(10-12)
L(14-16)
XL(18-20)
Medical or Other Information or Allergies (please send a snack for child with food allergies): _____________________________________________________________________________________
CHILD 2
Name: _____________________________Age: ___________
Last Grade Completed in School: __________________________________ T-Shirt Size (Circle One):! XS(2-4)
S(6-8)
M(10-12)
L(14-16)
XL(18-20)
Medical or Other Information or Allergies (please send a snack for child with food allergies): _____________________________________________________________________________________ Would you like your child(ren) to be placed in a group with another specific child? (We will do our best to honor requests.) _____________________________________________________________________________________ If your children's ages fall within the same grouping, would you prefer your children to be: placed in the same VBS group or separated into different VBS groups?
Parent/Guardian Name(s): _____________________________________
Phone 1: ______________________________
Email: _______________________________________
Phone 2: ______________________________
Address: ______________________________________________________________________________
Emergency Contacts Name & Phone: _____________________________________________ Name & Phone: _____________________________________________ Church Home: ________________________________________________________________________ Will your child(ren) be attending child care from 7-9 am? (There is no charge for the week of VBS): Y
N
PARENT PERMISSIONS: If you would like your child(ren) to participate in bounce house & all VBS activities, please sign the following statement of consent and release of liability. As a parent or legal guardian, you remain fully responsible for the actions and conduct of your child(ren), including any legal responsibility which may result. I hereby consent to participation by my child(ren) (named above) in this activity. I understand that this event will take place at the church facilities and that my child(ren) will be under supervision on the stated dates. I further consent to the conditions stated above regarding participation in this event. In consideration of my child's being allowed to participate in this activity, I agree to indemnify and hold harmless St. Paul Lutheran Church & School and its representatives, including chaperones, from any and all claims, including negligence, arising from or relating to my child's participation in this event. This indemnification and hold-harmless agreement does not apply to claims for intentional misconduct or gross negligence. VBS leaders have permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with this VBS program.
Parent/Guardian Signature: ________________________________________ Date: __________________
Hike cloud-shrouded ruins of Machu Picchu. Savor exotic flavors of the Amazon. Hear what daily life is like from kids in Peru.
Grab your passport for an unforgettable VBS trek where kids discover God’s good gifts for us all.
vacation bible school
June 19-23 Age
s 3 (& p otty trained !) throu gh 5th gra de. Register on the back of this form or online at
www.stpaulroseburg.org 9:00 am - 12:00 pm
free child care offered the week of VBS 7:00 - 9:00 am St. Paul Lutheran Church & School 750 W Keady Ct. | Roseburg, OR 97470 541-673-7212
