VBS Registration Form

Children(s) Information

How many children?

1 2 3 4 5

Child #1

First & Last Name

Birthday

Allergies/Medical Conditions

Child #2

First & Last Name

Birthday

Allergies/Medical Conditions

Child #3

First & Last Name

Birthday

Allergies/Medical Conditions

Child #4

First & Last Name

Birthday

Allergies/Medical Conditions

Child #5

First & Last Name

Birthday

Allergies/Medical Conditions

Severe Allergies & EpiPen Information

Are there meds or an epi-pen carried with carried? If yes complete a separate Epi-pen consent form.

Participant Support & Safety Needs

Should your child require 1:1 assistance please provide the name of the child care worker

Special needs (behavioural / emotional / physical)?

No Yes

If yes specify which child and special need

Consent/Waiver

As parent(s) and/or guardian(s), I/we do hereby authorize treatment under the direction of a licensed physician for the above-named minor(s) in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me/us at the phone number(s) listed above. The undersigned assumes responsibility for any costs connected with such treatment and hereby releases Liberty Pentecostal Church Bowmanville, where the child attends VBS, from any responsibility. I/we do hereby give the child/children listed on this form permission to participate in VBS at Liberty Pentecostal Church Bowmanville. I/we understand the possibility of unforeseen hazards and acknowledge the inherent risk involved. I/we agree not to hold Liberty Pentecostal Church Bowmanville or any of its leaders or assistants liable for any damages, injuries, or loss incurred.

Yes.

I give permission for my child(ren)'s photos or videos to be taken and used by Liberty Online Church for promotional or media purposes (social media, website, newsletters, etc.).

Yes No

Guardian/Parent Name

This address will receive a confirmation email

Address

Todays Date

Emergency Contact

First & Last Name

Phone

Relationship to the child(s)

Father Mother Grandparent Sibling Aunt/Uncle Family Friend

Friend Request

Please let us know if your child would like to be with a friend that is already registered in the same division.

What is the friends first and last name?

Liberty Newsletter & Ministry Updates

Receive weekly updates, upcoming events, and encouraging messages from Liberty Ministries. Stay informed and connected with everything happening in our church community.

Yes. No

VBS Registration Form

Description

Please Fix the Following