PLATTEVALLEY BAPTISTCHURCH

Child's Name *

First Name

Last Name

Parents/Gaurdian *

First Name

Last Name

Gender

Male

Female

Birthday

MM

DD

YYYY

Child 2

First Name

Last Name

Gender

Male

Female

Birthday

MM

DD

YYYY

Child 3

First Name

Last Name

Gender

Male

Female

Birthday

MM

DD

YYYY

Child 4

First Name

Last Name

Gender

Male

Female

Birthday

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Waiver

I hereby give permission for my child to attend & participate in all of Platte Valley Baptist Church's activities on /off the camp property & absolve Platte Valley Baptist Church from liability to me or my child(s) because of an injury received while attending camp at Platte Valley Baptist Church. In case of any accident or serious illness, I hereby authorize Platte Valley Baptist Church to call upon a physician of their choice and to follow his instructions. If emergency treatment or hospitalization is required, I request Platte Valley Baptist Church to notify me. I also understand that my campers picture or testimony may be used in promotional of the church.

Agree

Disagree

Time

Hour

Minute

Second

AM PM

Bus Ride

I would like my child to ride the bus to and from VBS.

Yes

No

Bus Address

Please pick my kid/s up at the address below

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country