VBS Signup

Child

List each child who will be attending. You can leave the last name blank if it is the same as the parent last name.

First name	Last name	Age	Dietary restrictions	Operations
First name	Last name	Age	Dietary restrictions

Parent/Guardian

List all adults who may be picking children up and will be available in the case of emergency. We will consider the first person listed to be the primary contact.

First name	Last name	Phone	Relationship	Operations
First name	Last name	Phone	Relationship Relationship Enter other…

Please provide the email address we should use to communicate with you about the VBS. We will only use it to communicate about the event and about your child.

Address

City

State

Zip code

Medical info

In the case of a medical emergency and you cannot be reached, please provide your insurance provider and your child's primary care provider name and number.

Insurance provider	PCP (primary care physician)	PCP phone
Insurance provider	PCP (primary care physician)	PCP phone

I allow my child to receive medical treatment if I am unable to be contacted.

I agree to the waiver and consent.

Waiver and Consent

By checking this box, I hereby consent to participation of my minor child in the programs, activities and events of Troy Church of Christ Vacation Bible School. I hereby release and forever discharge Troy Church of Christ, their agents and servants, successors and assigns, directors, trustee, officers, employees, and other representative against loss from any and all present or future claims, demands, or actions in law or in equity that may hereafter be made or brought by me or my child, by anyone on behalf of me or my child, or by anyone else on their own behalf for damages or any other legal or equitable remedy on account of any injury, illness, physical condition, inconvenience, or loss sustained by me or my child during participation in programs, activities or events sponsored by Troy Church of Christ.