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Registracion del Participante

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First Evangelical Presbyterian Church

Location

2000 West Jefferson Street

Kokomo, IN 46901

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Contact Ellen Engelhardt:

765-457-8201

first.epc.nursery@gmail.com

Primero, cuéntenos sobre usted:

Información de los Padres

Nombre

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Apellido

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Correo Electrónico

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Dirección 1

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Dirección 2

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Ciudad

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Estado/Provincia

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ZIP/Código Postal

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Teléfono de Contacto 1

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Teléfono de Contacto 2

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Mensaje de texto Teléfono

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Nombre del Contacto de Emergencia

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Relación del Contacto de Emergencia

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Teléfono del Contacto de Emergencia

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Afiliación de la iglesia local

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Where Did You Hear About Our Vacation Bible School?

Multiple selections are allowed.

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(Other - Please Specify)

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Comentarios

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Cuéntanos sobre tu participante

Open to children age 4 Through Completed Grade 5

Nombre

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Apellido

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Género

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Age

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Child must be at least age 4 as of June 22, 2026.

Fecha de nacimiento

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For children age 4 and up who have not yet attended kindergarten, please select Pre-K below. Kindergarten and Pre-K children will be placed in preschool crews. Children who have just completed grade 1, 2, 3, 4, or 5 will be placed in elementary crews.

Grado Saliendo

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¿Tienes amigos con los que te gustaría estar juntos? Haremos todo lo posible para juntar a los amigos seleccionados en el mismo grupo, pero no podemos prometer que todas las solicitudes serán posibles.

Amigo 1 Nombre

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Amigo 1 Apellido

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Amigo 2 Nombre

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Amigo 2 Apellido

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Alergias

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Preocupaciones Médicas

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Family Physician Name and Phone Number

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MEDICAL CONSENT

I hereby state that I am the parent or legal guardian of the above-named minor child. I authorize Ellen Engelhardt, Team Leader of Children and Family Ministries at First Evangelical Presbyterian Church, 2000 W. Jefferson, Kokomo, Indiana, to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above-named minor under general supervision and on the advice of any physician or surgeon licensed to practice in the state of Indiana. Please enter your name as a legal electronic signature.

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Date Signed

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PHOTO/VIDEO RELEASE

I consent to First Evangelical Presbyterian Church to use photos or videos of my child in publications which may include, but are not limited to, the church newsletter, church bulletin, church website, and printed media. Please enter your name as a legal electronic signature.

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Date Signed

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Comentarios

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