Register for VBS and VBX! 6:30-8:30pm nightly!

Child's Name (First & Last)

Street Address

Address Line 2

City, State, & Zip/Postal Code

Date of Birth (Month/Day/Year)

Grade (As of September)

Parent/Guardian Name (Title, First & Last, Suffix)

Phone Number

Emergency Contact Name (First & Last)

Phone Number

Medical - Does your child have any allergies, special needs (physical or learning disabilities) or special medical conditions?

Did you answer yes? If yes, explain any special needs, necessary medication, physical or learning disabilities. Please offer any other information which you feel may help us.

DISCLAIMER OF LIABILITY & RELEASE OF CLAIMS
Please note: Completion of online registration serves as your electronic signature agreeing to the following terms of liability and photo release. Please review the terms and conditions completely before submitting this registration. Thank you.

This Disclaimer of Liability and Release of Claims is to be executed by the participant, or if the participant is a minor, by the participant's parent/guardian. The Application for Program Registration(s) will not be accepted unless it has been executed.

In consideration of Salem Baptist Church accepting this registration I
agree to this disclaimer of Liability and Release of Claims, and give my informed consent for my child to participate.

Disclaimer: The participant assumes all risks associated with his or her participation in the programs offered by Salem Baptist Church accepts no liability for bodily injury, death, property or loss due to any cause whatsoever, including, without limitation, negligence on the part of Salem Baptist Church, including its elected officials, employees, agents and volunteers.

Release: The participant and his or her parents/guardians waive any and all claims they may now and in the future may have against, and release from all liability and agree not to sue, Salem Baptist Church and its elected officials, employees, agents and volunteers. This release includes all claims for bodily injury, death, property or loss sustained by the participant as a result of his or her participation in the programs and activities offered Salem Baptist Church including, without limitation, negligence on the part of the Salem Baptist Church, its elected officials, employees, agents and volunteers.

Emergency Authorization: In event of an emergency, I hereby authorize a leader of this activity, as an agent for me, to consent to: any x-ray examination; medical, dental or surgical diagnosis; treatments; or hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where services are rendered, either at a doctor's office or in a hospital. I expect that my family will be contacted as soon as possible.

Photographs: I understand that during VBS pictures will be taken of all the children at various activities and that some of these photos may be used for promotional purposes. I understand that no personal information will be divulged about my child.

I confirm that I have read this Waiver, Release and Indemnification Agreement, have asked and received answers to any questions I had concerning it's meaning, and execute it freely, without duress, and in full and complete understanding of its legal effect, and of the fact that it may affect my legal rights.

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Your Email

Texting (Please Select One)

Comments (Any additional information that we should be made aware of?)