CityLife Church VBS Sign-Up Question Title * 1. Child's Name Question Title * 2. Child's Age Question Title * 3. Child's Birth Date MM/DD/YYYY Date Question Title * 4. Child's Grade Question Title * 5. Parent/Guardian Name(s) Guardian #1 Guardian #2 Question Title * 6. Cell Phone Question Title * 7. Work Phone Question Title * 8. Email Address Question Title * 9. Preferred Contact Method Question Title * 10. Emergency Contact #1 Name Phone Question Title * 11. Emergency Contact #2 Name Phone Question Title * 12. Primary Doctor Name Phone Question Title * 13. Allergies or Special Needs Question Title * 14. Who may pick your child up at the end of VBS each day? Name & Relationship #1 Name & Relationship #2 Question Title * 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 Parent/Guardian Signature Date Done