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* 1. Child's Name

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* 2. Child's Age

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* 3. Child's Birth Date

Date

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* 4. Child's Grade

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* 5. Parent/Guardian Name(s)

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* 6. Cell Phone

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* 7. Work Phone

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* 8. Email Address

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* 9. Preferred Contact Method

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* 10. Emergency Contact #1

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* 11. Emergency Contact #2

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* 12. Primary Doctor

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* 13. Allergies or Special Needs

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* 14. Who may pick your child up at the end of VBS each day?

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* 15. By signing this form you are consenting to put your greatest treasure into our care, which is our  honor and pleasure. We will do everything we can to keep your child safe and sound as we  participate in Vacation Bible School (“VBS”). For each activity we keep in mind safety  considerations and emergency procedures so that if anything unfortunate happens we will be  ready. However, there are times when unforeseen circumstances beyond our control do occur,  and the statements below are intended to protect the congregation and staff of CityLife Church in those situations.  

 ----------------------------------------------------------------------------------------   In consideration of your accepting my child for participation in VBS, I hereby, for my  heirs, executors, administrators, and myself waive and release any and all rights and claims for  damages that I may have against CityLife Church and its agents, employees,  representatives, successors and assigns for any and all injuries suffered by myself or my child  that arise out of VBS sponsored by the above named organization.  

 I warrant that I have the right to authorize the foregoing and do hereby agree to hold the  above named organization harmless of and from any and all liability of whatever nature, which  may arise out of or result from such participation. 

For the consideration stated above, I further agree that in the event that my child or I  should make any claim against the above named organization for damages arising out of the  above named program, activity or sport, I will personally indemnify, defend, and hold harmless  the organization and its agents, employees, representatives, successors, and assigns against any  and all loss and damage, occasioned thereby, including attorney's fees.  

By signing below I give permission to treat my child in case of a medical emergency. By  signing below, I also give permission to CityLife Church to use photographs, videos, and other recording, likenesses and images in promoting other activities sponsored by the  church.  

I have read and understand this Agreement and have willingly placed my signature below  as evidence of my acceptance of all the conditions contained herein. 

Parent/Guardian Signature Below

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