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Participant Registration

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Registro en Español

Langlois Community Church

Location

94284 Main St

Langlois, OR 97450

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Contact Emily Mckenzie:

541-348-2301

emilywickstrom@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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Contact Phone 2

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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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The following additional people have my permission to pick my child up from VBS:

Alternate Pickup Name

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Alternate Pickup Phone

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Alternate Pickup 2 Name

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Alternate Pickup 2 Phone

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Home Church Affiliation

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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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Grade Entering

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Gender

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Date Of Birth

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Do you have friends you would like to be placed with? We will do our best to group selected friends together in the same crew, but we cannot promise all requests will be possible.

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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Friend 3 First Name

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Friend 3 Last Name

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Allergies: List any allergies or enter "None"

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MEDICAL CONCERNS and ACTIVITY RESTRICTIONS: List any medical concerns or enter "None"

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Comments

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LIABILITY AND MEDICAL RELEASE

By checking below, I give permission for my child, as named above, to participate in Langlois Community Church VBS, on the dates listed above. I hereby release Langlois Community Church employees and volunteers from responsibility and liability for any illness or injury that the above named child may sustain during any activity.

Further, I authorize the person in charge of first aid duty at Langlois Community Church VBS to administer first aid as required for illness or injury. In the case of emergency, I understand that all reasonable attempts to contact me at the phone numbers provided in this form will be made. However, if I cannot be reached, I hereby give permission for Langlois Community Church to seek emergency treatment if deemed appropriate.

I agree to the above Liability and Medical Release:

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PHOTO RELEASE

During the week, we will be taking pictures of the activities at Vacation Bible School. These photos will be used in a slideshow shown to event and church participants. By selecting the checkbox below, I grant permission for Langlois Community Church to take photographs or video of me and my family in connection with Vacation Bible School and authorize the church to use these images as described above.

PHOTO RELEASE

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