HOUSEHOLD INFORMATION

Name of Parent/Legal Guardian completing this form (required)

Email (required)

Phone (required)

Postal Address (required)

Church Affiliation

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EMERGENCY CONTACT

Emergency Contact (required)

Emergency Contact Phone (required)

Relationship to Child/ren (required)

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CHILD 1:

Child's Name (required)

Child's Sex (required)
---malefemale

Child's Age (required)

Completed Grade (required)
---PreschoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6

Allergies/Medical conditions

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CHILD 2:

Child's Name

Child's Sex
---malefemale

Child's Age

Completed Grade
---PreschoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6

Allergies/Medical conditions

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CHILD 3:

Child's Name

Child's Sex
---malefemale

Child's Age

Completed Grade
---PreschoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6

Allergies/Medical conditions

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CHILD 4:

Child's Name

Child's Sex
---malefemale

Child's Age

Completed Grade
---PreschoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6

Allergies/Medical conditions

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LIABILITY RELEASE
In the event of an emergency, I, the undersigned parent/legal guardian, understand that all will be done to contact me or the emergency contact named above. However, if neither can be reached, I give full permission to a representative of Kanawha Salines Presbyterian Church to seek medical attention in my absence for my son/daughter named on this form. I, the undersigned parent/guardian, hereby assume all risk, known or unknown, for my son/daughter, in connection with his/her attendance and participation in Vacation Bible School at Kanawha Salines Presbyterian Church, July 12-15, 2022. I acknowledge that participation in Vacation Bible School is voluntary and therefore FULLY RELEASE and discharge Kanawha Salines Presbyterian Church, its pastor, officers, and volunteer workers, from any and all liability in connection with any activities carried on at the Kanawha Salines Presbyterian Church Vacation Bible School program.
I accept

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MEDIA RELEASE
I, the undersigned parent/guardian, acknowledge that my son/daughter, as a participant in Vacation Bible School, may be photographed and/or captured on video during the Vacation Bible School. I hereby grant full permission to Kanawha Salines Presbyterian Church to use photographs or videos—in print, electronic, online, or other public media—of my son/daughter registered on this form and further release Kanawha Salines Presbyterian Church from any and all liability connected with the authorized use of words and image of my son/daughter.
I accept

Electronic Signature (required)

Today's Date (required)

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