VBS - Greatest Week of the Summer - Preschool (3's - PreK)
Please fill out this form and click submit.
First Name of Child
Last Name of Child
Parents' Name
Gender
Please select all that apply.
Female
Male
Childn's Birthday including year
Age
Please select all that apply.
3 years old
4 years old
5 years old
Address
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DC
DE
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MH
MI
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MT
NB
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Phone
Email
This address will receive a confirmation email
Any allergy, medial or special needs information we need to be aware of?
Emergency Contact Name & Number
LIABILITY RELEASE Every activity sponsored by SCPC is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By agreeing to this question, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree to hold SCPC, or its employees or volunteer assistants harmless for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are agreeing for the minor listed on this form and the signature is for both a medical and liability release. Our church’s insurance is excess insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is participating in a church-related activity. In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary.
Please select one option.
Agree
Disagree
Names of anyone else allowed to pick up your child:
If you regularly attend church, which one? If not, please list none.
How did you hear about our VBS?
MEDIA CONSENT I give my consent and permission for the taking of photographs and/or video of my child during 2018 VBS and waive and/or assign any and all rights (including copyright) in such media to SCPC for promotional use in print and online. SCPC will not use their full names with the picture of the students on their website, nor will it tag any children used on SCPC or Kids at the Creek facebook pages.
Please select one option.
Agree
Disagree
Payment
Regular ($25.00)
Family member volunteering discount ($20.00)
Will mail check (0)
Regular ($25.00)
Family member volunteering discount ($20.00)
Will mail check (0)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
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