VBS Registration/Consent Form

Please read carefully and fill in all blanks. By signing this form you may give up certain legal rights. Consent is required for participants under the age of 18. West Zion Mennonite Church is collecting and retaining this personal information for the purpose of enrolling your child/youth in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our church. This information will be maintained permanently as it is a requirement of our insurance company and legal counsel. If you wish West Zion Mennonite Church to limit the information collected, or to view your child’s information, please contact us.
Parent's/Guardians' Name(s):(*)
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Child 1:(*)
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Child 1 - Boy or Girl:(*)
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Child 1 - Birthday (including year of birth):(*)
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Child 1 - Age:(*)
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Child 1 - Completed Grade:(*)
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Child 1 - AHC#:
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Child 1 - Concerns - Please list any allergies, sensitivities, medications, conditions, and/or behavioral concerns of your child:(*)
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Child 2 - Name:
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Child 2 - Boy or Girl
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Child 2 - Birthday (including year of birth):
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Child 2 - Age:
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Child 2 - Completed Grade:
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Child 2 - AHC#:
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Child 2 - Concerns - Please list any allergies, sensitivities, medications, conditions, and/or behavioral concerns of your child:
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Child 3 - Name
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Child 3 - Boy or Girl
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Child 3 - Birthday (including year of birth):
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Child 3 - Age
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Child 3 - Completed Grade
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Child 3 - AHC#:
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Child 3 - Concerns - Please list any allergies, sensitivities, medications, conditions, and/or behavioral concerns of your child:
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Child 4 - Name
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Child 4 - Boy or Girl
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Child 4 - Birthday (including year of birth):
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Child 4 - Age:
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Child 4 - Completed Grade:
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Child 4 - AHC#:
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Child 4 - Concerns - Please list any allergies, sensitivities, medications, conditions, and/or behavioral concerns of your child:
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Child 5 - Name
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Child 5 - Boy or Girl
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Child 5 - Birthday (including year of birth):
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Child 5 - Age
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Child 5 - Completed Grade
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Child 5 - AHC#:
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Child 5 - Concerns - Please list any allergies, sensitivities, medications, conditions, and/or behavioral concerns of your child:
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Mailing Address:(*)
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Best Parent/Guardian Phone #:(*)
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Best Parent/Guardian eMail Address:(*)
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Emergency Contact (name & number :(*)
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Home Church (if applicable):
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Would you like more information about West Zion and its programs?(*)
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How did you learn of VBS at West Zion?(*)
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Please list anyone other than yourself who is authorized to pick up your child(ren) from VBS at West Zion:(*)
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I/we, the parents or guardians named above, authorize West Zion Mennonite Church to use photos/videos taken of my child(ren) during the week of VBS for the sole purpose of using it for a slide show for the closing program of VBS and/or to show to the West Zion congregation:(*)
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I/we, the parents or guardians named below, authorize one of the West Zion Mennonite Church Ministry Volunteers to sign a consent form for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant(s) named above. I/we, named below, undertake and agree to indemnify and hold blameless the Ministry volunteers, West Zion Mennonite Church, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant(s) named above as a result of being part of the activities of the West Zion Mennonite Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to events of the West Zion Mennonite Church.
I agree that my signature will be valid for this VBS Registration/Consent Form for the dates of July 12, 13, 14, 15, 16 of the year 2019:(*)
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Please mark today's date:(*)

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Parent/Guardian Signature:(*)
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