Spring Grove Community Vacation Bible School

PARTICIPANT: FULL NAME

NICKNAME

DATE OF BIRTH: MM/DD/YYYY

GRADE COMPLETED (or age as of September 1, 2017):

Pre-K3 (Age 3)
Pre-K4 (Age 4)
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Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade

PARENT/GUARDIAN NAME

DAYTIME PHONE NUMBER

ADDRESS

CITY, STATE, ZIP

PARENT EMAIL

PEOPLE AUTHORIZED TO PICK-UP MY CHILD FROM CAMP:

ALLERGIES (food/medical):

EMERGENCY CONTACT NAME

EMERGENCY CONTACT PHONE

HOME CHURCH

Sacred Heart Catholic Church
St. Paul Lutheran Church
Other

Comments / helpful info to best support my child at camp:

A PARENT/GUARDIAN MUST READ AND AGREE TO THE RELEASES BELOW BEFORE SUBMITTING THIS ELECTRONIC REGISTRATION FORM.

RELEASES: MEDICAL/PHOTO/PUBLICITY

By submitting this form to register my child for Spring Grove Community VBS, I have read and agree to the following: I will be responsible to physically sign a release upon arrival and before participation in VBS. MEDICAL RELEASE: I hereby give my permission for my child to fully participate in Spring Grove Community VBS. I hereby release on behalf of myself and my child, Spring Grove Community VBS, Sacred Heart Catholic Church, and St. Paul Evangelical Lutheran Church, its agents, employees, and volunteers from any and all liability arising out of or connected to these events, including personal injuries which my child might sustain. I understand that I will be notified in case of serious injury or illness. However in the event that I cannot be reached, I hereby give permission for my child named above to be medically treated by a physician or medical facility as appropriate. PHOTO/PUBLICITY RELEASE: I hereby give Spring Grove Community VBS, Sacred Heart Catholic Church, and St. Paul Evangelical Lutheran Church permission to publish in print, electronic, or video format the likeness or image of my child or audio recordings of my child. I release all claims against Spring Grove Community VBS, Sacred Heart Catholic Church, and St. Paul Evangelical Lutheran Church with respect to copyright ownership and publication including any claim for compensation related to use of the materials. Images, video and audio recordings of my child taken or recorded can be used in print, broadcasting and other forms of advertising; brochures, newsletters and other publications; on the Spring Grove Community VBS website, Sacred Heart Catholic Church website, and St. Paul Evangelical Lutheran Church website; and in other activities to promote Spring Grove Community VBS and partnering churches (Sacred Heart Catholic Church and St. Paul Evangelical Lutheran Church) and inform the public about Spring Grove Community VBS and the partnering churches. These photos, video and other images or recordings may be used by Spring Grove Community VBS and partnering churches without payment of fees, royalties or other remuneration. By clicking "submit" on this form, I agree to the above terms.

I AM THE PARENT/GUARDIAN OF THIS PARTICIPANT:

YES
NO