Child's Name *

First Name

Last Name

2nd Child's Name

First Name

Last Name

3rd Child's Name

First Name

Last Name

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian Cell Phone *

(###)

###

####

Parent Guardian Home Address *

Please complete all fields of home address. For Country, type USA.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Photo/Video Release *

Throughout the week of VBS, photographs and/or video will be taken and possibly used for publications related to Reformation Lutheran Church such as church bulletins, newsletters, presentations and website. As a Parent/Guardian, I give permissions to Reformation Lutheran Church to photograph and/or record my child/children while they are attending the 2024 VBS program at Reformation Lutheran Church.

I DO give permission

I DO NOT give permission

Medical Release *

As a parent/guardian, I authorize the treatment by a qualified doctor of the minor(s) listed in the event of an medical emergency while attending the 2024 VBS program at Reformation Lutheran Church

I DO authorize treatment

I DO NOT authorize treatment

Final Authorization *

By selecting I DO agree below, I attest that I am the parent/guardian for the child(ren) listed and all information provide above has been answered fully and correctly.

I DO Agree

I DO NOT Agree