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 NameLast Name

Parent/Guardian Name:*

First NameLast Name

Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Number*

Area CodePhone Number

Parents' Work Number

Area CodePhone Number

Cell Number

Area CodePhone Number

Email Address:*

example@example.com

Local Phone Number and Address:

Check if same as above

Local Phone Number

Area CodePhone Number

Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age Information:

Child's Birthdate*

MonthDayYear

Grade Completed June 2020*

In Case of an emergency, contact:

Emergency Contact's Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Second Emergency Contact's Name

First NameLast Name

Second Contact's Phone Number

Area CodePhone 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?

YesNo

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*

Printed Name*

First NameLast Name

Date*

Date

VBS Registration Form July 20-24, 2020