Summer Camp Detailed Registration Form

Information received is confidential and is being gathered for the purposes of serving your child while in the care of Bethel Evangelical Missionary Church. Any medical information collected here serves to authorize Bethel Evangelical Missionary Church, and its staff and volunteers, to obtain medical assistance in emergencies.

Child's Name *

First Name Last Name

Parent/Guardian Name: *

First Name Last Name

Home Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Number *

Area Code Phone Number

Parents' Work Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Email Address: *

example@example.com

Local Phone Number and Address:

Check if same as above

Local Phone Number

Area Code Phone Number

Local Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Age Information:

Child's Birthdate *

Month Day Year

Grade Completed June 2020 *

In Case of an emergency, contact:

Emergency Contact's Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Second Emergency Contact's Name

First Name Last Name

Second Contact's Phone Number

Area Code Phone Number

May we have permission to photograph your child and use your child’s photograph for internal church use only ie. in a slide show of the VBS week?

*

Yes No

The safety of your child is our primary concern. Precautions will be taken for their well being
and protection.

I/we, named below, undertake and agree to indemnify and hold harmless Ministry Personnel, Bethel Evangelical Missionary Church, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the Bethel Evangelical Missionary Church, as well as of any medical treatment authorized by the supervising individuals representing the Church. This consent and authorization is effective only when participating in or traveling to events sponsored by the Bethel Evangelical Missionary Church.

Purpose and Extent

Bethel Evangelical Missionary Church is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our Church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Bethel Evangelical Missionary Church to limit the information collected, or to view your child’s information, please contact us.

I have read, understood and agree with the above.

Parent Signature *

Clear

Printed Name *

First Name Last Name

Date *

Date

VBS Registration Form July 20-24, 2020