(One per child)

Child’s name: ______________________________________Child’s age: _____________
Date of birth: ______________ Gender_________ Last school grade completed:________
 Allergies or other medical conditions:_________________________________________
Do you have a friend you would like to be placed with? If so who?________________________________

If you have multiple children you only need to fill this section out once
Name of parent(s):	
Street address:	
City:		State:		ZIP:	
Home telephone: (_______)	
Parent/caregiver’s cell phone:	
Home e-mail address:	
In case of emergency, contact:	
Relationship to child:	
Home church:	
Name and Phone # of alternate pick up person___________________________________

Release Information
By signing below, I acknowledge and accept the risks of physical injury associated with participation in the activity described above.  Except for gross negligence on the part of the sponsor, the parent/guardian of the participant accepts personal, financial responsibility for any bodily or personal injury sustained during the activity.  Further, the parent/guardian of the participant promises to hold harmless the sponsoring organization and its representatives for any injury related to the activity.  If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable arbitration process.

Parent/Guardian Signature						Date			

By signing below, I certify that photographs or videotapes of my child participating in VBS activities may be reproduced and utilized by Agape Christian Church.

Parent/Guardian Signature						Date			

Parent information can be found on _____________________Registration form