| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Birthday: |
__________________________________ |
| *Grade completed by June 2022: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| School Attended: |
__________________________________ |
| Friend Request K-5th (1 friend request only): |
__________________________________ |
| Teacher Request K-5th (1 teacher request only): |
__________________________________ |
| *Does this learner have special needs?: |
__________________________________ |
| Allergies, Medical, & Special Needs: |
|
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| *Cell Phone or Preferred Phone: |
(______)______-________ |
| Alternate Phone: |
(______)______-________ |
| Email: |
__________________________________ |
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| *Authorized Pickup #1: |
__________________________________ |
| *Authorized pickup #1 Phone Number: |
__________________________________ |
| Authorized Pickup #2: |
__________________________________ |
| Authorized Pickup #2 Phone Number: |
__________________________________ |
| I hereby grant, voluntarily and with full understanding, to First Baptist Church Allen, a license to the following: Use and storage of my name and image, by means of digital or film photography, video photography, audio recording or other documentation, including printed or electronic publications, and website created by or for FBC Allen for its sole benefit with respect to the activity, namely Vacation Bible School. If I am signing this agreement on behalf of a minor child I hereby warrant that I am the legal parent or guardian of the child and that I have the legal authority to sign this agreement on behalf of the child. If a dispute over this agreement or any claim for damages arises, I agree to resolve this matter through a mutually acceptable alternative dispute resolution process. If I cannot agree with FBC Allen upon such a process, the dispute will be submitted to a three-member arbitration panel of the American Arbitration Association for final resolution. |
| *I give my consent to the above statement: |
Yes
No (circle one) |
| *Are you currently a member of a church?: |
Yes
No (circle one) |
| If so, where?: |
__________________________________ |
| What brought you to VBS at FBC-Allen?: |
__________________________________ |
