VBS Enrollment Form

Contact Office 610-213-9587 or Christine - 484-557-2760

The information that is provided by this form is gathered to assist us in identifying appropriate care for those who attend camp in case of medical emergency. Those representing the camp in an official capacity at all events have the right to refuse any attendees who do not provide this information before or during registration for a particular event or activity. Charges per child is $25 the whole week. You may provide the form of payment in person (memo - VBS) or electronically.

CAMPERS INFORMATION Ages 6-12yrs

Name

First Name

Last Name

Email Address

Date of Birth

YYYY

Age

Grade Last Completed

(Copy of last report card required)

Gender

Female

Male

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

EMERGENCY CONTACT

Name

First Name

Last Name

Relation To Participant

(Listed Above)

Phone

(###)

###

####

Secondary Contact

(Phone, Email, Etc.)

INSURANCE INFORMATION

Is The Participant Covered By Family Medical/Hospital Insurance

Yes

Carrier Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Group #

Name of Insured

Policy Holder or Insurance ID #

Allegries

Indicate Any Other Known Medical Condition(s) That We Should Be Aware Of

(Seizures, Diabetes, Low Blood Sugar, Heart Problems, Asthma, Etc.)

DISCLAIMER

By registering, I give permission for my child to participate in this program sponsored by Trinity Episcopal Church. I fully understand that his/her participation may entail the risk of physical injury. I agree to waive any claim of any kind whatsoever, whether resulting from an injury or otherwise, and further agree to release, indemnify, and hold harmless the program, Trinity Episcopal Church, and their respective directors, officers, employees, agents and/or representatives from any and all liability occurring as a result of his/her participation in the program. I will be personally responsible for any financial costs incurred because of his/her participation and/or medical expenses incurred as a result of any injury. Furthermore, I understand that Trinity Episcopal Church assumes no liability for lost, misplaced, stolen, and/or damaged property and I hereby agree to release Trinity Episcopal Church from such liability. Your child may have his/her picture taken during this year’s VBS week at Trinity Episcopal Church. These pictures may be used for the closing ceremony photo slide show, internet photo albums, and/or church flyers or brochures.