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Participant Registration

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Registro en Español

Grace

Location

375 Main Street

Bedminster, NJ 07921

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Contact Sandie Kirkpatrick:

908-719-1093

sandie.kirkpatrick@gmail.com

First, Tell Us About Yourself:

Parent Information

First Name

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Last Name

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Address 1

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Address 2

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City

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State/Province

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ZIP/Postal Code

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Contact Phone 1

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Emergency Contact Name

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Emergency Contact Relationship

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Emergency Contact Phone

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As parent/legal guardian, I remain legally responsible for any actions taken by my son/daughter. Signing hereby releases Grace Fellowship Chapel and the directors thereof from any responsibility and liability for injury or loss occurring while participating in any activities at the church, or under it's supervision.

Electronic Signature for Consent & Date (Month, Day, Year)

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I hereby authorize and consent to an x-ray, examination, anesthesia, medical, surgical, or dental diagnosis or treatment and hospital care to be rendered under the general or specific supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. *I also authorize (if I so provide it) the administration of my child's prescribed epinephrine auto injector.

Electronic Signature for Consent & Date (Month, Day, Year)

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Children's Doctor (First name, Last name)

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Doctor's Phone Number

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Insurance Company & Policy Number

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Click here for your FREE Friends With God Kids Activity Pack

By checking the box you will be emailed your Free Friends With God Kids Activity Pack.

You are also agreeing to receive emails about family resources from Lifetree. You can unsubscribe at any time. We value your privacy. Your information will not be shared with a third party. Lifetree is a division of Group Publishing, the creators of Group VBS and other faith-building resources. Click to learn more about Lifetree.

Tell Us About Your Participant

First Name

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Last Name

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Please choose from the menu below the grade your child willenter in September 2023.

*** PreK must be 4 years old by January 1, 2022

*** Nursery is for volunteers only.

Grade Entering

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Gender

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Date Of Birth

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Allergies

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Medical Concerns

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Do you have a friend you would like to be placed with? Please enter one name below. We will do our best to honor your request.

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I hereby authorize Grace Fellowship Chapel to use images of my child in the VBS slideshow ONLY to be shown Friday during camp and presented Sunday at Grace Fellowship Chapel.

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Electronic Signature for Consent & Date (Month, Day, Year)

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