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Participant Registration

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Registro en Español

Chantilly Bible Church

Location

4390 Pleasant Valley Rd

Chantilly, VA 20151-1342

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Contact Rita Barillas:

703-263-1188

rita.barillas@chantillybible.org

First, Tell Us About Yourself:

Parent Information

First Name

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Last Name

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Contact Phone 1

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Spouse name (if applicable)

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Spouse's email

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Spouse's contact phone

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Address 1

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City

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ZIP/Postal Code

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Alternate Emergency Contact Information

Emergency contact name - DO NOT put your name or spouse's name here. This is an alternate contact when we cannot reach a parent. We will always try to reach parents first.

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Emergency Contact Relationship

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Emergency Contact Phone

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Safety Information

Name of any individual(s) who MAY NOT pick up your child

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Permission for Emergency Care and Medical Release

I, the undersigned parent/guardian, do hereby grant permission for my child(ren), named below, to receive the proper medical treatment in the event that he/she may sustain injury or illness during the period of EBC. I hereby authorize the EBC staff to obtain or provide medical treatment for my child(ren) for such injury or illness during EBC. The EBC staff has my permission in an emergency to take my child(ren), at my expense, to the hospital emergency room deemed appropriate by the rescue squad or the adult advisor(s). The hospital and its medical staff have my authorization to provide treatment, which a physician deems necessary, including anesthesia, for the well-being of my child(ren). I understand every effort will be made to contact me in such a situation.

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Security Agreement

Each family participating in EBC will receive three security cards that show the family identification number. The EBC staff will release a child to anyone who presents a security card with a family ID that matches the child’s family ID. It is imperative therefore that parents and guardians protect the cards and give them only to people authorized to pick up their children. The EBC staff will not release a child to anyone that does not have the matching security card, except for the parent or guardian upon presentation of picture identification. I understand the security mechanism being used to protect my child and agree to fulfill my responsibility of protecting the security cards, presenting picture identification when requested, and informing the EBC staff of anyone who may not pick up the child.

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Image Notification

Image Notification: CBC may use photos and videos taken at events in our publications, website and services, but will not identify children in these productions. Images can be taken down at a parent's request.

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Phones and other Electronic Devices Policy

Cell phones and other electronic devices should be left at home. If a child brings a cell phone or other device, it will be held for them until they are picked up at the end of the evening.

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Optional questions to help us understand who is coming to EBC

Home Church Affiliation

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How did you hear about our EBC?

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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

Registration is open for preteens who have completed 4th grade through 6th grade this past year.

First Name

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Last Name

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Please choose the grade your child has COMPLETED this past year.

Grade Leaving

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Gender

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Date Of Birth

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Does your child have allergies? If Yes, please provide additional information.

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We care for the success and safety of each child at EBC. Does your child have any special needs, learning disabilities, medical conditions or behavioral diagnosis we can prepare to support? If Yes, please provide additional information.

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Please list one or two friends that your child would like to be with (groups are by grade and gender). Due to small group size, we cannot guarantee friends will be placed together, and we cannot make changes the week of EBC.

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Friend 1 first name

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Friend 1 Last Name

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Friend 2 First Name

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Friend 2 Last Name

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