VBS 2010 Registration Form

Your email address: (Note: a valid email address is required.)

Street Address:
City: State: Zip:

Parent(s): Phone (h/c): (w):

Emergency Contact (other than parent/guardian):
Relationship: Phone:

*If you have made arrangements for someone else to pick up your children, other than the individual who dropped your children off, please inform the registration staff.

*If your child has food allergies, please contact Sandy Challgren 815-748-4463 to discuss snacks.

How did you hear about our VBS?
Do you know anyone who attends Kishwaukee Bible Church?
Do you attend church? Where?
Would you like to find out more about Kishwaukee Bible Church?
Is there anything you would be interested in at Kishwaukee Bible Church?

Other information you would like to include:

MEDICAL TREATMENT AUTHORIZATION

I, (parent/guardian), hereby state that I am the parent or legal guardian of the above named Children and hereby give my consent and approval for the Children to participate in the VBS activity. On behalf of myself and the Children, I hereby waive, release, and agree to hold harmless Kishwaukee Bible Church and the staff, employees, agents, organizers, volunteers, participants, and persons involved in the operation, organization, sponsorship, supervision or participation of this VBS and related activities, for, from, and against any claim or cause of action of any nature whatsoever, whether or not presently known or contemplated, that may be available to the Children or their parents, guardian(s), heirs or assigns, arising out of any injury, accident, or illness, whether such injury be physical, social, economic, or otherwise, arising in any way out of or in connection with each Child’s participation in such activities, including his/her transportation to, from, or during the same. Further, I hereby grant my consent and permission to provide emergency medical treatment to any or all of the Children if, in the judgment of those person(s) supervising the same, the need should arise during the course of the activities. I understand and agree that I am responsible for all medical care expenses incurred to treat any of my Child’s injuries including, without limitation, physician, hospital, lab, drug and device expenses.