VBS - HIGHLANDS BAPTIST CHURCH

Highlands Baptist Church
2017 VBS Registration

Child Information

* Indicates required field

Child's Name *

First

Last

Birthdate *

Age *

Gender *

Last Grade Completed *

VBS Class *

Address *

City *

State *

Zip Code *

Transportation Type *

My child would like to be in class with the following friend(s) *

The following sibling(s) will also be attending VBS with my child *

Comment *

My child attends the following church: *

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Home Phone *

Mobile Phone *

Email *

Emergency Contact Name *

Phone Number *

Relationship to Child *

Medical Information

Child Has Allergies *

If "Yes", list allergies *

Child Has Medical Condition(s) *

If "Yes", list conditions *

Insurance Company *

Policy Number *

Disclaimer

The undersigned gives permission to his or her child to participate in the above named activity and releases Highlands Baptist Church, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by the undersigned for any member of his family, in attendance, and the undersigned agrees to defend and indemnify Highlands Baptist Church, its officers, employees, and agents, from any liability or loss they might sustain by reason thereof. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the director of children's ministry to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above.

I have read and agree to the above disclaimer: *

Submitted by: *

Acknowledgement

By submitting this registration form you agree that any photographs taken of your child at or during this event are the property of Highlands Baptist Church and may be used in future publications as deemed appropriate.

Submit

Highlands Baptist Church​2017 VBS Registration

Highlands Baptist Church
2017 VBS Registration