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2022 Online VBS form

Parent/Custodian Information

Name(Required)

First Last

Enter the name of the child(ren)'s parent or custodian.

Full Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Enter Email Confirm Email

Registration

Number of children on this registration:(Required)

Enter the number of children on this registration (must have same parent or custodian).

Child 1

Child 1 Name(Required)

First Last

Child 1 Birthday(Required)

Child 1 Grade Completed(Required)

Select the grade completed in 2021-22 school year.

Child 1 Are immunizations current?(Required)

Yes

No

Child 1 Known Allergies or Medical Conditions

Child 1 Medications List (and times needed if must be administered at camp)

Child 2

Child 2 Name(Required)

First Last

Child 2 Birthday(Required)

Child 2 Grade Completed(Required)

Select the grade completed in 2021-22 school year.

Child 2 Are immunizations current?(Required)

Yes

No

Child 2 Known Allergies or Medical Conditions

Child 2 Medications List (and times needed if must be administered at camp)

Child 3

Child 3 Name(Required)

First Last

Child 3 Birthday(Required)

Child 3 Grade Completed(Required)

Select the grade completed in 2021-22 school year.

Child 3 Are immunizations current?(Required)

Yes

No

Child 3 Known Allergies or Medical Conditions

Child 3 Medications List (and times needed if must be administered at camp)

Child 4

Child 4 Name(Required)

First Last

Child 4 Birthday(Required)

Child 4 Grade Completed(Required)

Select the grade completed in 2021-22 school year.

Child 4 Are immunizations current?(Required)

Yes

No

Child 4 Known Allergies or Medical Conditions

Child 4 Medications List (and times needed if must be administered at camp)

Child 5

Child 5 Name(Required)

First Last

Child 5 Birthday(Required)

Child 5 Grade Completed(Required)

Select the grade completed in 2021-22 school year.

Child 5 Are immunizations current?(Required)

Yes

No

Child 5 Known Allergies or Medical Conditions

Child 5 Medications List (and times needed if must be administered at camp)

Child 6

Child 6 Name(Required)

First Last

Child 6 Birthday(Required)

Child 6 Grade Completed(Required)

Select the grade completed in 2021-22 school year.

Child 6 Are immunizations current?(Required)

Yes

No

Child 6 Known Allergies or Medical Conditions

Child 6 Medications List (and times needed if must be administered at camp)

Contact Information

Provide a contact person and phone number where contact can be reached during Bible School time.

Contact Name(Required)

First Last

Contact Phone(Required)

Healthcare Insurance

Physician's Name(Required)

Physician's Phone(Required)

Physician's Address(Required)

Insurance Company(Required)

Policy Number:(Required)

Policy Holder Name(Required)

Pickup Authorization

I hereby authorize the following person to pickup my child(ren) from VBS being held at Faith Lutheran Church. If there are any changes in these arrangements, I will give advance written notice.

Name(Required)

Phone(Required)

Relationship(Required)

Permissions

Permission to use photographs.

My child(ren)'s photo may be used in post VBS slideshows at Faith Lutheran Church.

I agree

Permission for Medical Care(Required)

I hereby enroll and give permission for my child(ren) to participate in the planned activities of Vacation Bible School at Faith Lutheran Church. In the event that I cannot be reached in an emergency, I authorize the church leaders to seek medical care for my child(ren). Further, I authorize the staff to secure any medical or emergency treatments deemed necessary. The camper’s parent or guardian is the primary carrier of accident/health insurance. The information listed above is accurate. If there are any changes, I will contact the church with the correct information.

I agree

Vacation Bible School Covenant

Child Agreement - Covenant

As a participant in Vacation Bible School and a child of God, I understand and agree to the following expectations:
I will choose to participate fully in Vacation Bible School. I will choose to respect all people, including myself, choosing to treat others as I would like to be treated.
I will choose to listen to the VBS leadership team and volunteers.
I will choose to use my words to build others up or I will choose to be quiet.
I will choose to maintain self-control. I will not bring harm to myself or to others.
I will choose to be respectful of the facilities and grounds where Vacation Bible School is held.
I understand that if I damage other people’s property, I am responsible for replacing/repairing it.
I understand that if I choose to break this Conduct Covenant, there are consequences.
I will take responsibility for my actions.
I understand that if I choose to harm myself, or others, my parent/guardian will be contacted, and I will be sent home.

I(we) agree - child(ren)

Child(ren)'s Signatures for Convenant(Required)

Include each child's signature in the box.

Parental Agreement - Covenant(Required)

I have read this Conduct Covenant and enter into it with my child(ren). I will encourage my youth to abide by it. I understand that should my child(ren) choose to break this Covenant, every effort will be made to contact me and my child(ren) will be sent home. I also understand that if I am not reachable, the emergency contact listed on the registration form will be contacted.

I agree - parent or guardian

Will you please tell us

What church are you a member of?

How did you hear about our Bible School program?

Volunteer Opportunities

Please check all areas where you would be able to help

Please note: Group guides stay with the same group of kids each day, getting them to where they need to be. Craft, Recreation, Music, and Science Leaders or helpers plan and teach for 4 sections of each age group, ideas are provided—each section is 20-25 minutes.

Lead Opening/Closing

Kitchen Committee

Group Guide

Craft Leader or Helper

Recreation Leader or Helper

Music Leader or Helper

Science Experiment Leader or Helper

Group Guide Preferred Age Group

Please indicate the preferred age group you would like to guide.

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FAITH LUTHERAN ELDRIDGE

500 W. LeClaire Road

Eldridge, IA 52748

Phone: (563) 285-4501
Email: FaithEldridge@netins.net

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