Theme image

Participant Registration

Go Back

Registro en Español

Piedmont Park SDA Church

Location

4801 A Street

Lincoln, , NE 68510

Map It

Contact Ilka J. Fuentes :

308-589-0842

ilkajuditruiz@gmail.com

First, Tell Us About Yourself:

Parent Information

First Name

This field is required.

Last Name

This field is required.

Address 1

This field is required.

Address 2

This field is required.

City

This field is required.

State/Province

This field is required.

ZIP/Postal Code

This field is required.

Country

This field is required.

Contact Phone 1

This field is required.

Contact Phone 2

This field is required.

Emergency Contact Name

This field is required.

Emergency Contact Relationship

This field is required.

Emergency Contact Phone

This field is required.

Home Church Affiliation

This field is required.

Release Forms

The following fields are for our three release forms; medical, media (photo video), all claims. Please be sure to read carefully before selecting your answer. If you have any question please feel free to contact us. Becasue we deeply care for the wellbeing and safety of our participants and our staff members we are required by policy to have these forms signed by you (parent/guardian). We might collect your physical signature during our fist night of VBX. We will print out your filled form for you to review and sign. If you have more than one participant, this will be a blanket form to cover all your children. This is a one time process that will speed up our first night check in. Thank you so much for your patience and cooperation!

Medical Form

I [ ]give [ ] do not give permission to the VBX Nurse to provide first aid in case of emergency. I authorize the nurse (if necessary) to take measures and arrange for medical and hospital treatment, on behalf of the health and well being of my child/ren. I release Piedmont Park Seventh-day Adventist Church, the staff, and volunteers from claim of liability due to sickness or injury. I accept all financial responsibilities concerning any medical emergency. I also accept responsibility to have my child/ren picked up immediately in the event of illness, accidents or for disciplinary reasons.

This field is required.

Media (Photo & Video) Release Form

I [ ]give [ ] do not give permission for my child/ren to be photographed and recorded/filmed during the 2025 Vacation Bible Experience at Piedmont Park Seventh-day Adventist Church. I give permission to Piedmont Park Seventh-day Adventist Church to use those photographs, videos, and other recordings such as livestream, to be used only for promotion purposes in other activities, social media platforms and website sponsored by the church. I trust that the church, staff and volunteers will use this content appropriately by keeping my child/ren safety and well being.

This field is required.

Release of All Claims

In consideration for my child/ren being allowed to participate in the 2025 Vacation Bible Experience activities sponsored by Piedmont Park Seventh-day Adventist Church, I hereby release, discharge, indemnify, and agree to hold harmless Piedmont Park Seventh-day Adventist Church, its directors, officers, and employees, agents and all volunteer personnel from any and all liability for personal injuries and/or damage(s), injury, or illnesses that may be suffered by my child/ren which name/s will be listed below in the participant/s form.

This field is required.

I HAVE FULLY INFORMED MYSELF OF THE CONTENT OF THIS RELEASE FORMS BY READING IT BEFORE I SIGNED IT AND HAVE RECEIVED PROPER INFORMATION REGARDING ITS CONTENTS AND THE ACTIVITIES INVOLVED.

This field is required.

I have read and understand this agreement and have willingly placed my signature below as evidence of my acceptance of all the conditions contained herein.

This field is required.

Signature of Parent/Guardian (Type your name and today's date here):

This field is required.

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

This field is required.

Last Name

This field is required.

Grade Entering

This field is required.

Date Of Birth

This field is required.

Gender

This field is required.

Allergies - please list medication, food, or environmental (if aplicable):

This field is required.

Please list any medications to be taken by child (including dosage and times) if applicable:

This field is required.

Medical Concerns

This field is required.

Special instructions or information

This field is required.

Comments

This field is required.

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. Please enter the names below.

This field is required.

— or —