2019 VBS – Peace Works

Please fill out one form per child to simplify our grouping during VBS.

Participant's Name (required):

Last Grade Level completed (required):

Participant's Age (required):

Parent/Guardian Full Name(s) (required):

Street Address:




Home Phone:

Cell Phone (required):

Work Phone: -

E-Mail Address (required):

Person(s) other than parent/guardian authorized to pick-up :

Person(s) NOT authorized to pick-up:

Home Name Church and Address:

Allergies, medical information (required):

May we apply bug spray?

The following Medical and Liability Agreement will have to be signed the first night this child attends.

1. General Release of Liability Form

I, (parent/guardian), have requested St. Paul Presbyterian Church/Highlands Presbyterian Church Camp to allow (child) to participate in Vacation Bible School. As a condition of this benefit, I the undersigned, do hereby agree to the following: I understand that
(child)'s participation in this activity can expose him/her to dangers both from known and unanticipated risks. Acknowledging that such risks exist, I hereby release and discharge St. Paul Presbyterian Church/Highlands Presbyterian Church Camp, its officers, agents and employees from any and all claims or liability for personal injury or property damage (child) may suffer while participating in the activity: including, but not limited to, any claim arising out of any condition of the premises at which the activity is held or the conduct of any person in connection with the preparation for, supervision of, or conduct of any activity, whether planned or unplanned. I specifically agree to release and hereby release St. Paul Presbyterian Church/Highland Presbyterian Church Camp and the officers, agents and employees of the VBS for negligence at VBS.

2. Emergency Medical Care

I, (parent/guardian), give my permission to St. Paul Presbyterian Church/Highlands Presbyterian Church Camp to call a doctor for medical or surgical care for our child, (child's name), should an emergency arise. It is understood that a conscientious effort will be made to locate me/us before emergency action will be taken, but if this is not possible, the expenses of the emergency medical treatment or care will be accepted by me.

3. Photo Release

I understand that pictures will be taken of my child during VBS and will be used during a slide show presentation at the end of VBS, local church publications (newsletter, website, facebook) and/or at local church services.

Parent/Guardian Signature and Date will be requested at the registration table.