Name of Parent/Guardian *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

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####

Other Phone

(###)

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CHILD 1 *

First Name

Last Name

Child 1 Date of Birth *

MM

DD

YYYY

CHILD 2

First Name

Last Name

Child 2 Date of Birth

MM

DD

YYYY

CHILD 3

First Name

Last Name

Child 3 Date of Birth

MM

DD

YYYY

CHILD 4

First Name

Last Name

Child 4 Date of Birth

MM

DD

YYYY

Liability Release *

In consideration of St. John’s Episcopal Church allowing the above child(ren) to participate in Vacation Bible School activities, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless St. John’s Episcopal Church, its directors, employees, volunteers, and agents (collectively herein the “Church”) from any and all liability, claims, or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever that may be incurred by the undersigned and the above child(ren) while involved in Vacation Bible School. Furthermore, on behalf of my minor child(ren), I hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in activities involved therein. As well as releasing the child(ren), if necessary, for transportation to and from the Vacation Bible School location, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless St. John’s Episcopal Church, its directors, employees, volunteers, and agents from any and all liability, claims, or demands for accidental personal injury in the process of transportation.

I release St. John's from liability

Medical Treatment Permission *

I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency X-ray 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 on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) pursuant to this authorization.

I authorize St. John's to emergency treatment

Photo/Video Permission *

I give my consent to St. John’s Episcopal Church to use photo or video images taken of my child(ren) in church brochures, advertisements for the church, on the website, in social media, and in other church publications as they see fit. I agree to hold harmless St. John’s Episcopal Church from any liability which may result from the use of said picture(s). This form will apply throughout my child(ren)’s tenure at St. John’s Episcopal Church’s Vacation Bible School. **None of the photos will be for personal use.**

I give permission