Abundant Grace Community Church

Student's First Name:

Student's Last Name:

Nickname:

Age:

Gender:
Male
Female

Grade just finished? :

Email:

Please list all known allergies:

Medical Issues and/or Special Needs:

Parent First Name:

Parent Last Name:

Address 1:

Address 2:

Country:

City:

State:

Zip/Postal Code:

Email Address:

Home Phone #:

Cell Phone #:

Emergency Contact's First Name:

Emergency Contact's Last Name:

Emergency Phone Number:

Alternate Pick up's First Name:

Alternate Pick up's Last Name:

Alternate Pickup's Phone Number:

General Information:

Medical Release: Permission for the VBS staff to administer basic first aid to my child (named above) in the event of an injury. I understand that the VBS staff will contact emergency services in the event of a significant injury and all expenses for such emergency services will be paid by me.
Yes
No

Photo Release: Does the above name church permission to copyright and use photographs/videos taken at VBS of the minor designated above in any manner or form for any purpose lawful at any time. If yes, I waive any right that I may have to inspect or approve the finished product or written copy, that may be used in conjunction therewith, or the use to which it may be applied?
Yes
No

*By submitting this form, I give permission for my child (named above) to attend the Vacation Bible School (VBS) listed above. I understand that the information I give for this registration will only be used by the VBS hosting church, and that all registration information will be removed from the hosting site by December 31 of this year.

AGCC vacation bible school