VBS 2019 Form

First Baptist Church

515 N. Ladd Street

Pontiac, Illinois 61764

815.842.4321

Backyard Bible School

At Backyard Bible School, your students will enjoy an interactive, energizing, Bible-based good time as they use a wordless book of colors to learn about the plan of salvation through Jesus!

With plenty of crafts, outdoor activities, and learning to be done, your child won't want to miss a moment. We'll even provide lunch at the end of each day's lessons! Please sign your child up by completing and submitting the form below!

Meet Us in the Backyard:

July 26th - July 30th

10:00 am - 12:00 Noon

**Sign your kids up for this exciting expedition by filling out and submitting the form below**

Student Name

Enter Your Child's Name

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Parent/Guardian Name(s)

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Email:

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Address:

Enter Address

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City:

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State:

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Zip code:

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Phone:

Enter Phone Number

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Secondary Phone:

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Date of Birth:

Your child's date of birth

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Age:

Your child's age

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Last Grade Completed:

Last Grade Your Child Completed

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Special Needs/Allergies/Medical Information/Other:

Enter Any special information we should know about your child

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Name:

Enter Name of Emergency Contact

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Phone Number:

Phone Number of Emergency Contact

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Name:

Enter Name of Emergency Contact

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Phone Number:

Phone Number of Emergency Contact

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Name(s) of those who may pick up this child from VBS:

Enter names here

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Transportation Needed:

Yes

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My child will stay for lunch:

Yes

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PHOTO RELEASE: First Baptist Church / VBS has my permission to use my child's photograph publicly in VBS materials. I understand the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or compensation shall become payable to me by reason of such use.

Required

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by First Baptist Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

Required

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization. PLEASE NOTE: in the unlikely event of a medical emergency, every effort will be made to contact a child’s parent or guardian.

Required

Parent/Guardian Name

Enter Parent/Guardian Full Name

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Date:

Enter Date of Completion

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Emergency Contact #1

As Parent/Guardian of the above named student, I agree to the following:

Emergency Contact #2