Side by Side Ministries of St. Paul ~ St.

John Lutheran Church VBS 2013 Registration Form

Tell It on the Mountain!

Located at Tall Timbers Campground 340 South Christy Chapel Rd. Port Clinton Vacation Bible School, July 22nd July 26th, 9AM NOON Preschool through 6th grade

Childs Name

Date of Birth

Age/Grade

Childs Name

Date of Birth

Age/Grade

Childs Name

Date of Birth

Age/Grade

Parent/Guardian Name ( ) ( )
Home Phone Cell Phone

Parent/Guardian Name ( ) (
Cell Phone

Home Phone

Address City, State Zip Primary Emergency Contact ( ) ( )

Home Phone Cell Phone

Address City, State Zip Secondary Emergency Contact ( ) (

Cell Phone

Home Phone

People NOT authorized to pick up my child(ren) 1. 2.

When you arrive each morning, it will be your responsibility to sign your child in and report who will be picking your child up from Vacation Bible School. Vacation Bible School July 22nd July 26th

Hospital/Clinic Preference

(
Physicians Name

Phone Number

Insurance Company

Policy Number

ALLERGIES/SPECIAL HEALTH CONSIDERATIONS/MEDICATIONS:

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedure as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

Parents/Guardians Signature

Date

I give permission for my child to attend St. Paul/St. John Lutheran Church VBS activities. I release St. Paul/St. John and individuals from liability in case of accident during activities related to St. Paul/St. John Lutheran Church and VBS activities, as long as normal safety procedures have been taken.

Parents/Guardians Signature

Date

We are asking each child to bring a white t-shirt with them to VBS. Please place the washed t-shirt in a plastic bag labeled with the childs name. We will be tie-dyeing these shirts one day during VBS. Childs Name Childs Name Childs Name Childs T-Shirt Size Childs T-Shirt Size Childs T-Shirt Size

Sponsored by Side-by-Side Ministries, the parishes of St. Paul and St. John Lutheran Church Return application form to St. Paul Lutheran Church: 541 Church Rd., Lakeside-Marblehead, OH 43440
Questions? Contact: Chrissy French (VBS Director) (419) 341-4653 OR Pastor Chris Young (419) 734-1662