Gotta Move VBS Re-Registration

Hi — we're excited you're here to register your child for VBS!

What You'll Need Most of this is in your amazing brain, but you'll probably need your insurance card and phone to look up your emergency contact's number.

Thank you! We can't wait to hang out with your kids at Gotta Move!

Guardian Information

Name

Guardian Information is the same as 2018

Yes No, please fill in below

Mobile Phone

This address will receive a confirmation email

Address

Pick-Up

Who may pick up your child(ren) after VBS? (If blank, your chil(ren) will only be released to a parent.)

Emergency Contact

Emergency Contact is the same as 2018

Yes No, please provide below

Parents are always our first contact in the event of an accident or emergency, so please do not put your or your spouse's name here. List an additional emergency contact.

Emergency Contact Name

Emergency Contact Phone

Relationship to child/children

Children You are Registering

Name

Shirt size

Name

Shirt Size Child's Medium Child's Large Adult Small Adult Medium Adult Large Adult XL

Name

Shirt Size Child Medium Child Large Adult Small Adult Medium Adult Large Adult XL

Name

Shirt Size Child Medium Child Large Adult Small Adult Medium Adult Large Adult XL

Name

Shirt Size Child Medium Child Large Adult Small Adult Medium Adult Large Adult XL

Additional Notes

Medical Info

Has your medical info changed since 2018?

No Yes, please provide below

Hospital Insurance Yes No

Insurance Provider

Policy #

Name of Insurance Policy Holder

Waiver · Release · Signature

Waiver Agreement

I authorize an adult, in whose care the minor has been entrusted, to transfer my child to the emergency room if a parent or emergency number cannot be contacted. I consent to an X-ray examination, anesthetic, medical, surgical or dental diagnosis or trea I do not authorize the aforementioned waiver..

Photo/Video Release

I give permission for Oak Grove Church to use any photographs or videos taken of my child in, but not limited to slideshows, newspaper, web pages, social media, television, etc. I do not consent to use of my child's photo/video.

Text Communication

I give Oak Grove Church permission to send text message updates and reminders using the church’s Breeze app. (Note that texts are one-way, and will come from short code #: 96167.) I do not give permission to receive text messages.

Consent To Report

By checking this box I consent to Oak Grove Staff to report suspicions of child abuse, elder abuse, and harm to self to the appropriate agencies, such as child protective services, a law enforcement agency, or Iowa's toll-free child abuse reporting hotlin

E-Signature

By checking this box I acknowledge that I have read the above medical release and that all of the information contained in this registration form is true to the best of my knowledge.

Type Your Full Name

Gotta Move VBS Re-Registration

Hi — we're excited you're here to register your child for VBS!

Thank you! We can't wait to hang out with your kids at Gotta Move!

Description

Please Fix the Following