VBS Registration Form 2016-PDF - Le Sueur United Methodist Church

Le Sueur Ecumenical Vacation Bible School
2016 Child Registration Form
Location: Zion UCC: 240 S. Elmwood Ave. Le Sueur, MN 56058
Dates: Monday, August 8th – Friday, August 12th
Time: 9:00 a.m. – 12:00 p.m.
VBS 2016 is sponsored by Zion UCC, First Lutheran and the United Methodist Churches of Le Sueur.
Neither child(ren) nor parent(s) need to be members of any of these congregations or of
any congregation to participate in the VBS program.
To participate in VBS the child can be age 3 through completing 5th grade.
(Children must be age 3 (and potty trained) by June 1, 2016 to be registered for VBS).
Please fill out a separate registration form for each child participating in VBS.
Name of Child:
Age:
Grade Just Completed:
Address:
Medical Allergies and/or Concerns:
Home Congregation:
Transportation: How will your child be leaving VBS every day?
 Parent/Guardian
 Transit Bus
 Other – Please Explain:
OR
 Transportation is an issue to get my child(ren) to/from VBS.
Parent(s) or Guardian(s):
Phone Number(s):
Email Address:
Emergency Contact:
Phone Number(s):
Relationship to Child:
How did you hear about VBS:
The cost for VBS 2016 is $20 per child or $45/family of 3 or more children*.
Please indicate your form of payment:
Cash – Amount:
Check – Amount (Check #):
Please make checks payable to: Le Sueur Ecumenical VBS
*If you are not able to pay the suggested amount, please contact the office of one of the churches listed above.*
Registration form(s) and Payment are due by: Friday, July 15, 2016
Mailing Address: United Methodist Church, 730 S. 6th, Le Sueur, MN 56058
If you have any questions regarding VBS 2016, please contact: Jane King 665-3156
or the United Methodist Church office at 507-665-2314 or [email protected]
Minor Participation Authorization and Consent to Emergency Medical Treatment Form:
I hereby give my consent to have my minor child
(name of child) to
participate in the following activity of Le Sueur Ecumenical Vacation Bible School at Zion UCC Church
(which is sponsored by Zion UCC, First Lutheran Church and the United Methodist Church of Le Sueur)
from August 8th, 2016 – August 12th, 2016. I ‘DO’ consent to any medical, surgical, x-ray, anesthetic or
dental treatment that may be deemed necessary for my minor child. I understand that efforts will be
made to contact me prior to treatment, but in the event I cannot be reached in an emergency, I give
permission to the activity leader to make the decisions necessary for treatment. I give permission to
the attending physician to treat my minor child. As parent or legal guardian, I understand that I am
responsible for the health care decisions of my minor child and agree that my insurance plan is the
primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor
child. Any insurance policy of the Zion UCC Church sponsoring this event will be used as the secondary
coverage.
Signature/Date of Parent or Legal Guardian:
Date:
Social Media Consent Form:
I
GIVE /
DON’T GIVE Le Sueur Ecumenical Vacation Bible School my permission to use
my child’s name,
________, image(s) in print and/or social media distributed by
the churches listed above.
Signature/Date of Parent or Legal Guardian:
Date:
VBS Field Trip Consent
I
GIVE /
DON’T GIVE my permission for
(name of
child), who has completed second grade or higher to walk (or in case of inclement weather, ride a
rented bus) with their group leaders to and from the local nursing home on Friday, August 12th.
Signature/Date of Parent or Legal Guardian:
Date: