VBS Registrion form 2016

St.Monica’sEpiscopalChurch
2016VacationBibleSchool
RegistrationForm
Pleasecompletethisform,following
directionsforeachsectionandsignbelow.
NameofParent/Guardian
Address
Work/CellPhone Home/CellPhone
EmailAddress_______________________________________
ChurchAffiliation(optional) Emergencycontactperson EmergencyPhone Foreachchild,listinformationintheblankspacesbeloweachheading.
(Pleaseprint)
Child’s Name
(First)
Age
(Last)
T-Shirt
Size
Allergies/MedicalConcerns
YS
YM
YL
YXL
T-ShirtSizes
YouthSmall YouthMedium
YouthLarge YouthExtraLarge
AS
AM
AL
AXL
AdultSmall
AdultMedium
AdultLarge
AdultExtraLarge
ConsentforTreatment
I,theundersignedparent/legalguardianoftheabovenamedchilddoherebyauthorizeSt.
Monica’sEpiscopalChurchtoprovideorarrangefortheprovisionoffirstaidoremergency
treatmenttomychildintheeventofanyaccident,injury,orillness.Iunderstandthatattempts
willbemadetocontactparentoremergencycontactperson,howeverifeithercannotbe
reachedIfurtherconsentthatSt.Monica’sEpiscopalChurchwillobtainwhatevermedical
treatmentisnecessaryincludingtreatmentbyparamedicsoranylicensedemergencyroom
staffofanylicensedgeneralhospital.Ialsoagreeanycostsincurredfortreatmentaremy
responsibility.
Initials:___________
InjuryRelease
Iherebyvoluntarilyreleaseandforeverdischarge,andagreetoindemnifyandholdharmless
fromanyandallclaims,demandsorcausesofactioninanywayconnectedwith,orarisefrom
mychild’sparticipationinvacationbibleschoolundertheauspicesofSt.Monica’sEpiscopal
Church.Thisindemnificationspecificallyincludesanycostsorattorney’sfeeswhichSt.
Monica’sEpiscopalChurchmayincurinordertodefenditsagents(includingchurch,itsofficers,
employees,teachers,leadersandvolunteers)againstanyclaimsordemands,aswellasany
costsorattorney’sfeesincurredinenforcingthisAgreement.
Initials:___________
PhotoandVideoRelease
IgivepermissiontoSt.Monica’sEpiscopalChurchtophotographmychildatVacationBible
School.Igivepermissiontocopyright,use,andpublishthephotographsforanylawfulpurpose,
includingnewspaperarticles,churchpublications,andthechurchwebsite.
Ihavereadandunderstandtheabove:
Initials:___________
Igive______________________________________________________________________(list
allchildren’snamesthatapply)permissiontoparticipateinthisprogram.
Parent/guardian
Signature_______________________________________ Date_______________________
[email protected]
T-Shirtsizeselectionwillbemadeonthefirstdayofcamp.PaymentcanbemailedtoSt.
Monica’sorpaidduringsign-inonchild’sfirstdayofcamp.