VBS Registration: The Pirates Who Don't Do Anything Families, please complete one form per child. Thank you!
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Last Name
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First Name
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Age
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Month of Birth
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Day of Birth
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Year of Birth
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Child's Grade (Fall 2008)
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Sex
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Male
Female
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Child's Address
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City
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State
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Zip
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Parent's/Guardian's Name
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Parent's/Guardian's Home Phone Number
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Parent's/Guardian's Cell Phone Number
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Person(s) to be contacted in case of emergency:
Please include Name, Phone Number, and Relationship to Child.
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Does your child have any medical condition(s) that we should be aware of?
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Yes
No
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If so, please explain.
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Please list other siblings that will be attending VBS.
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My child would like to be in a class with the following friend or friends.
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I would like to volunteer to help with...
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I give permission for my child to participate in the above named activity and releases Louisa Baptist Church, it officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by the undersigned for any member of his family, in attendance, and the undersigned agrees to defend and indemnify Louisa Baptist Church, its officers, employees, and agents from any liablity or loss they might sustain by reason thereof.
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I accept
I decline
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In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the director of children's ministry to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above.
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I accept
I decline
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Insurance Company
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Policy Number
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I confirm I am the parent or gaurdian of the child listed above. By accepting you are also agreeing that any photographs taken of your child at or during this event are the property of Louisa Baptist Church and may be used in future publications as deemed appropriate.
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I accept
I decline
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