Sign Up for V.B.S 2011

It’s time to plan vacation bible school! It will be summer fun for all ages.

Week of August 8th to the 11th from 5:30 - 8:00 PM.

It will be a four - day event from Monday through Thursday.

Enroll online now!

Student First Name: *

Student Last Name: *

D.O.B:

MM/DD/YYYY

Gender:

Male

Female

Grade Fall '11: *

Address:

City:

State:

Zip:

Home Phone: *

Family Email:

Parent/Guardian Name: *

Parent/Guardian Phone: *

Parent/Guardian Name:

Parent/Guardian Phone:

Who will pick up your child?:

List all parties that will pick up your child from VBS

Emergency Contact Name: *

Enter name of somebody that can be contacted in case of emrgencies

Emergency Contact Phone: *

Health Concerns/Allergies:

Medical Information:

Any pertinent medical information that could affect treatment?

MEDICAL RELEASE AND PERMISSION: *

I Authorize

I Do Not Authorize

I hereby authorize an adult staff member or appointed volunteer leader of St. John Lutheran Church to seek medical treatment for my child in the event of an accident or medical emergency. This authorization is effective during Vacation Bible School activities

Photo/Image Release: *

I Authorize

I Do Not Authorize

I hereby authorize St. John Lutheran Church to use my child's photographic or video images(s) on its web site, newsletter, or any other publication

Parent/Guardian Name: *

Type name of parent/guardian authorizing release.

Date: *