VBS 2022

We are so excited to open registration for Vacation Bible School 2022!

ROCKY RAILWAY VBS

Date: August 1-5, 2022

Time: 9:00 am – 12:00 noon

Grades: Entering Kindergarten – Entering 5th grade

Space is Limited! Please fill out a unique registration form for each child.

Problems registering? Please email us at [email protected]

Stepney Baptist Church Vacation Bible School Registration and Medical Release Form

Child’s Name(Required)

Date of Birth

Grade Entering(Required)

Authorized Person(s) to pick up my child(Required)

Home Address(Required)

Home Phone Number:(Required)

Parent’/Guardians’ Name:(Required)

Mother’s Work:(Required)

Mother's Cell:(Required)

Father’s Work:(Required)

Father's Cell:(Required)

Does your child have any specific health issues or allergies?

Health/Allergy Issues(Required)

Please write N/A if no health issues or allergies.

Physician’s Name(Required)

Physician’s Phone Number(Required)

Date of last Tetanus Shot(Required)

Hospital Preference(Required)

Health Insurance Company(Required)

Policy ID #/Group #(Required)

Insurance Company Phone(Required)

*Emergency Contacts: *Please list any adult that has permission to pick up your child in case of an emergency when you cannot be reached. Please let your child’s group leader know in the morning if this person is picking up your child at the end of the day. A driver’s license may be required.

Full Name(Required)

Phone Number(Required)

I/we the undersigned parent(s) or guardian(s) of (enter child's full name here)

do hereby authorize adult volunteers of Stepney Baptist Church, in the case of any injury is that is not serious enough for a hospital, to administer medical aid or CPR by a Certified Adult Leader. In the case of an emergency, I give the adult leaders of Stepney Baptist Church as agent(s) for the undersigned, to take my child/children by ambulance and to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from all liabilities Stepney Baptist Church and any of its ministers or volunteer leaders while my child/children are attending Vacation Bible School during August 1 – 5, 2022.

Print Full Name Below

Parent/Guardian Signature

Date

I approve of this child's photograph's use in the VBS closing slide show

Yes

Please email me a copy of this completed registration

Email Address