Valparaiso Baptist Church

Please fill out a separate application for each student going. Applications are due June 10th, 2024.

SCHEDULE OF EVENTS:

June 26-28: 5:30 PM - 8:00 PM
June 29: FAMILY DAY

Name (Required)

Email Address (Required)

Student Full Name:

Last grade completed:

Birthday:

Parent or legal guardian(s) full names:

Parent(s) phone number:

Pickup person #1 first name and last:

Pickup person may be asked to see ID.

Pickup person #2 first name and last:

Pickup person may be asked to see ID.

Emergency contact #1 name and phone number:

Emergency contact #2 name and phone number:

Food allergies:

Medical concerns:

Sibling(s) attending VBS:

Student's favorite snacks/drinks:

Can your child’s photo be used in promotional material? (Required)

Permission Slip & Emergency Medical Waiver (Required)

I understand that this waiver pertains to any child participating in Vacation Bible School from June 26-29, 2024, and that the activities will take place at Valparaiso Baptist Church (612 Emmettsburg St, Valparaiso, IN 46385). EMERGENCY: In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental, allergic, or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child when I am not immediately available for consultation. I understand that every effort will be made to contact me as the guardian of my child in case of emergency. By answering "yes" below, I understand and agree with the statements above.

Child Conduct Acknowledgement (Required)

CHILD CONDUCT: I fully understand that for the safety of the children and the counselors, certain rules and regulations will be upheld. By signing this document, I agree that my child must accept and obey all rules and requirements governing conduct during VBS activities. It is understood that VBS may disallow my child further participation in VBS and VBS related activities if it is determined that they are in violation of these standards. By answering "yes" below, I understand and agree with the statements above.

Liability Waiver (please sign parent/guardian full name below) (Required)

I understand that this waiver pertains to any child participating in Vacation Bible School from June 26-29, 2024, and that the activities will take place at Valparaiso Baptist Church (612 Emmettsburg St, Valparaiso, IN 46385). EMERGENCY: In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental, allergic, or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child when I am not immediately available for consultation. I understand that every effort will be made to contact me as the guardian of my child in case of emergency. By signing my name below, I understand and agree with the statements above.

Valparaiso Baptist Church

612 Emmettsburg St, Valparaiso, IN 46385