VBS Start the Party • Liberty Chapel Community Church

STUDENT INFORMATION

First Name

Last Name

Date of Birth

School Grade

Mailing Address

Mailing City

Mailing State

Mailing Zip Code

Mobile Number

Email Address

Other Siblings Enrolled in VBS? *

Yes

Sibling Name

EMERGENCY CONTACTS

Primary Contact Name

Primary Contact Phone Number

Alternate Contact Name

Alternate Contact Phone Number

MEDICAL INFORMATION

List allergies or type "none" if there are none

Please list all medical concerns or type "none' if there are none

VBS photos/videos are taken for promotional purposes related to Liberty Chapel Community Church. These pictures appear in various media outlets such as but not limited to, Liberty Chapel Community Church website and Instagram.

By submitting this form I, the legal guardian of my child(ren) give permission to attend Liberty Chapel's Vacation Bible School program.

I hereby release and hold harmless Liberty Chapel Community Church and its volunteers from any and all present and future claims of any kind or nature arising from my childs attendance and participation. I acknowledge my child must adhere to all the rules, regulations and instructions pertaining to the safety and protection of the participants, and that failure to comply could exclude my child from participation. Should by child not follow the rules, I may be required to pick up my child at any time during the course of the event.