Register for VBS

Family Information

Primary Phone

Alternate Phone

Mailing Address

Physical Address (if different than Mailing)

If person bringing & picking up your child(ren) is different from parent/guardian listed:

Address

Phone #

Emergency Contact

Relationship to Student Father Mother Grandfather Grandmother Great-grandfather Great-grandmother Brother Sister Uncle Aunt Guardian Foster Parent Granduncle Grandaunt Other

Phone Number

Authorized Pick-Up Person(s)

For safety reasons, we will not release any student to anyone other than their parent, emergency contact, or a person appointed by their parent(s). Please list alternate person(s) who has/have your permission to pick up your child(ren) from FBCA.

Phone 1

Phone 2

I certify that my child(ren) is/are physically sound and free from infection or communicable disease.

The staff at FBCA has my permission to seek emergency medical treatment for any or all of the listed children should them deem it necessary.

I authorize FBC staff to involve my child(ren) in photos for publicity.

I agree to indemnify, protect, defend, and hold harmless Faith Bible Church Alturas, their leadership, employees, volunteers, its Director and staff from and against any cost, damage, expense, claim, or liability caused by or arising out of injury, including death, to my child(ren) or property damage while attending or as a result of attendance at Faith Bible Church Alturas, and any attorney's fees and/or costs. Liability Release

Please Note: We will require a signature on the day of our event to certify all information you have provided is correct. Thank you!

Student Information

Gender

Birth Date

Age Group

Food Allergies

Details

Medical Concerns

Details

I have more students to register