Register for VBS

Family Information

Address

Primary Phone

Phone Number

Alternate Phone

Emergency Contact Phone

Relationship to Student Father Mother Grandfather Grandmother Great-grandfather Great-grandmother Brother Sister Uncle Aunt Guardian Foster Parent Granduncle Grandaunt Other

Alternate Pickup Phone

Student Information

Gender

Birth Date

Age Group

Food Allergies

Details

Medical Concerns

Details

Medical/Liability Release Yes No In the event of an illness or accident that requires immediate medical treatment to my child(ren) at a time when a parent cannot be located, I give permission for an approved representative of Youngsville Free Methodist Church to authorize such treatment. I will not hold the church or medical personnel responsible. I assume responsibility for any medical bills incurred. In signing this, I understand that every attempt will be made to contact the parent or guardian, physician or other persons listed for emergency contact. I release, forever discharge, agree to hold harmless, and indemnify Youngsville Free Methodist Church and the representatives thereof from any and all liability, claims, or demands for personal injury, sickness, or death, as well as property damages and expenses of any nature whatsoever which may be incurred by my child(ren) or for which my child(ren) may be liable to others in the course of participation in church activities.

Publication Permission Yes No I give my permission for my child's picture to be used in publications connected with Youngsville Free Methodist Church.

Check In Permission Yes No My child has permission to walk to and from the Youngsville Free Methodist Church for VBS. They are able to check themselves in and out each day.

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