VBS Camp Registration

Child's Last Name
Child's First Name
Date of Birth
As of June 2017,
Last Grade Completed
Parent name(s)
Email
Best phone number to reach me:
Second Phone number
Street Address
City
State
Zip
Tell us about any allergies or food restrictions
Tell us about any prescriptions or over the counter medicines your child is taking:
Tell us about any special needs?
Tell us any other helpful information (illness, activity restriction):
At the end of the day, my child will be picked up by:

Secondary Contact Person:

In the event of an emergency, and I cannot be reached, please contact:
Emergency Contact Phone
Emergency Contact Relationship
Is this your child's first time at VBS Camp?
What is your church affiliation?

I agree to grant St. Anne’s Parish and First Presbyterian permission to photograph, videotape, or audiotape, my child’s participation at VBS Camp. I further agree that any or all the materials recorded may be used, in any form, as part of any future production(s) made by and for St. Anne’s Parish and First Presbyterian, and further that such use shall be without payment of fees, royalties, special credit, or other compensation. If recorded materials are used in newsletter or web-site, or the Diocesan newsletter or web-site the name of the participant will not be identified.

I agree.

By submitting this form, I give permission for my child to attend VBS Camp from July 3-7, 2017. I have disclosed all significant medical, health and special needs information about the participant. I give permission to share information as needed for the well being of my child. In the event that medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, and the secondary contact cannot be reached, and my child needs emergency medical attention, I give my permission for the staff to seek service of a licensed physician to provide the necessary care, or my child’s well being.