VBS Participant Registration 2023

Participant Registration Info

Please fill out the information below for the child partipating in Stellar VBS at Porter Apostolic. Please submit one form per child

Particpant Name

Birthdate (mm/dd/yyyy)

Age

Gender

Allergies

None HAS ALLERGIES

Please list any allergies your child has in the box:

Please list any medical concerns our VBS staff should be aware of below:

Please list any additional notes or information our VBS staff should be aware of:

Has your child ever been diagnosed with ADD, ADHD, dyslexia, autism, or any other learning behavioral disorder?

Yes No

If yes, please explain in detail:

Guardian Information

Parent/Guardian First & Last Name:

Address:

Email:

This address will receive a confirmation email

Parent/Guardian Phone:

Emergency Contact #1

Emergency Contact First and Last Name:

Emergency Contact Phone:

Relation to Participant:

Emergency Contact #2

First and Last Name:

Phone:

Relation to Participant:

Waiver Release

I (participant guardian) hereby give permission for my child to attend and participate in Porter Apostolic Pentecostal Church's

Yes No

Liability Release

In consideration of Apostolic Pentecostal Church of Porter allowing the above child to participate in Vacation Bible School activities, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Porter APC, its directors, employees, volunteers and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above child(ren) while involved in Vacation Bible School.

Yes No

Furthermore, I [and behalf of my minor child] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in activities involved therein.

Yes No

Medical Treatment Permission

I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

Yes No

Photo Permission

I give my consent to Porter APC to use photo or video images taken of my child in church brochures, advertisements for the church, on the website, in social media, and in other church publications as they see fit. I agree to hold harmless Porter APC from any liability which may result from the use of said picture(s). This form will apply throughout my child's tenure at Porter APC's Vacation Bible School. **None of the photos to be taken will be for personal use.

Photo Release

Yes NO PHOTOS

VBS Participant Registration 2023

Description

Please Fix the Following