VBS - Greatest Week of the Summer - Preschool (3's

First Name of Child

Last Name of Child

Parents' Name

Gender Female Male

Childn's Birthday including year

Age 3 years old 4 years old 5 years old

Address

Phone

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. 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. Agree Disagree

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

VBS - Greatest Week of the Summer - Preschool (3's - PreK)

Description

VBS - Greatest Week of the Summer - Preschool (3's - PreK)

Description

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