Child Attending VBS on June 27-July 1, 2021 *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Primary) *

This will be the first number used for an emergency contact.

(###)

###

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Phone (Secondary)

(###)

###

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Secondary Emergency Contact

First Name

Last Name

Phone Number for Secondary Emergency Contact

(###)

###

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Medical Release *

By checking this box, I, the undersigned parent or guardian of the above registered minor, do hereby authorize adult volunteers of New Life EC Church as agents for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability New Life EC Church and any of its ministries or leaders in the event of an accident enroute, during and returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence.

Photography Release

By checking this box, I, the undersigned parent or guardian of the above registered minor, hereby gives New Life EC Church permission to use pictures of said minor on their website, social media, etc. for informational and promotional purposes.

Today's Date *

MM

DD

YYYY