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VBS REGISTRATION FORM |
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Potomac Falls Anglican Church
at St. Matthew's Church, For age 4 and rising grades K – 5th |
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$30 one child, $45 for 2 siblings, or $55 per family
Mail this form with
payment to:
VBS, Potomac Falls Church,
46859 Harry Byrd Highway, Suite 101, Sterling, VA, 20164
(703) 404-0900
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Student Name:___________________________________ Birth
Date:____________ Fall Grade:_______ Allergies or other medical conditions:_______________________________________________________ T-Shirt size L(14-16) _________ M(10-12) _________ S(6-8) _________ XS(2-4) ________ |
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Student Name:___________________________________ Birth
Date:____________ Fall Grade:_______ Allergies or other medical conditions: _______________________________ ______________________ T-Shirt size L(14-16) _________ M(10-12) _________ S(6-8) _________ XS(2-4) ________ |
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Student Name:___________________________________ Birth
Date:____________ Fall Grade:_______ Allergies or other medical conditions: ______________________________________________________ T-Shirt size L(14-16) _________ M(10-12) _________ S(6-8) _________ XS(2-4) ________ |
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Parent's Names______________________________ Name of
adult picking up child________________ Address ________________________________________________________________________________ Daytime Phone _______________________ Evening Phone ________________________ Emerg/Cell ___________________________ The undersigned gives permission to his or her child/children to participate in the above named activity and releases Potomac Falls Church, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by the undersigned for any member of his or her family, in attendance, and the undersigned agrees to defend and indemnify Potomac Falls Church, its officers, employees, and agents from any liability or loss they might sustain by reason thereof. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the director of children’s ministry to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child/children as named above. Signed:
_______________________________________________ Date:
____________________________ Insurance Company: ____________________________________ Policy No. ________________________ By signing this registration form you agree that any photographs taken of your child/children at or doing this event are the property of Potomac Falls Church and may be used in future publications as deemed appropriate.
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