CommunityBaptistChurch

Vacation Bible School Registration

Child's Name

required

Date of Birth

required

Age

required

Last Grade Completed

required

Mother's Name

required

Mother's Phone Number

required

Father's Name

required

Father's Phone Number

required

Address

required

Mailing address, city, state, zip

Emergency Contact Person

required

Emergency Contact Phone Number

required

Medical History

Does your child have allergies?

required

Yes

Option added and selected

List allergies

If you answered yes to the question above, please answer.

Does your child take prescribed medications?

required

Yes

Option added and selected

List prescribed medications

If you answered yes to the question above, please answer

Has your child had COVID-19 in the last 14 days?

required

Yes

Option added and selected

Has your child been exposed to anyone with COVID-19 in the last 14 days?

required

Yes

Option added and selected

Transportation

Does your child need transportation to Vacation Bible School?

required

Yes

Option added and selected

If Yes, please contact the church office

Required Waiver of Responsibility

In consideration for attending this program, I, the undersigned, intending to be legally bound, hereby for myself, heirs and executive administrator, waive and release any and all rights for damages I may have with Community Baptist Church, and verify that I am voluntarily attending Vacation Bible School (VBS) at 2100 Durham Road, Langhorne, PA, with my parent and or legal guardian’s consent.

Signers Full Name

required

Signers Email Address

required

Signature required

Date Signed

required

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