CAC Vacation Bible School 2023

Child Registration Form

Parent / Guardian Name:

Mailing Address:

Email:

This address will receive a confirmation email

Home Phone:

Cell Phone:

Emergency Contact Name & Number:

Child's Name:

Child's Date of Birth: mm/dd/yy

Last Grade Completed (as of 6/13/23):

PreK Kindergarten 1st 2nd 3rd 4th 5th 6th

Age:

Special Needs / Allergies / Other Concerns:

Home Church (if you attend locally):

Liability / Photography Release:

I further acknowledge that any child registered on this form, as a participant in Vacation Bible School at Coudersport Alliance Church, may be photographed or captured on video during the Vacation Bible School program and activities. I hereby grant full permission to Coudersport Alliance Church to use photographs or videos in print, electronic, online, or other public media of the child registered on this form and further release Coudersport Alliance Church from any and all liability connected with the authorized use of words and image of the child registered on this form.

I have read and agree to the above Liability Release and Photography/Video Authorization

Yes No

Electronic Signature of Parent / Guardian

CAC Vacation Bible School 2023

Description

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