Emergency contact or additional pickup person (name and phone number).
Anyone picking up the student must be listed on this form and may be asked for ID.
Last grade completed: (Required)
Does your child need to remain with a parent or guardian during VBS for any reason (e.g., medical, emotional, or behavioral support)? If yes, please provide the name of the parent or guardian.
Please note: any parent volunteer must fill out an application to volunteer at VBS.
Permission Slip & Emergency Medical Waiver
I understand that this waiver pertains to any child participating in Vacation Bible School, 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
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)
I understand that this waiver pertains to any child participating in Vacation Bible School, 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.
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