VBS Registration

VBS 2021 Registration

Child Information

* Indicates required field

Child's name *

First

Last

Last Grade Completed *

Allergies or Special Concerns *

Parent/Guardian Information

Your Name *

First

Last

your Email *

your Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Please list names and contact information of up to three people who may pick up your child OTHER THAN YOURSELF:

1. *

First

Last

1. Phone Number *

2. *

First

Last

2. Phone Number *

3. *

First

Last

3. Phone Number *

Childcare will be available from 12-4:30 PM for $5/child (or $20/family). Lunch and snacks provided each day. Pickup by 4:30 PM.

Sign my child up for childcare *

Yes No

Photo Release/Medical Release:
I am the legal parent or guardian of the child or youth listed above. I hereby give my permission and full consent for my child or youth to participate in the above listed event. In consideration for my child or youth’s participation in the event, I hereby release, acquit and hold harmless Elm Springs United Methodist Church, and all of their staff, agents, servants, employees and volunteers from any and all liability for any damages of whatsoever kind, seen or unforeseen, which may at any time result to me, my child or youth, or my family on account of or in any way related to my child’s or youth’s participation in this event. I consent to the collection and use of my OR my child’s personal images by photography or video recording at ESUMC events. I acknowledge these images may be used on ESUMC website, newsletters, publications and social media accounts.

I agree with the above *

Yes No

Submit