VBS Registration

June 11-15, 2018


General Information
Child's Name *
Child's Name
Address *
Phone *
Emergency Contact Number *
Emergency Contact Number
Parental Authorization
Note: Only the individuals listed below may pick up your child from VBS.
Please list your child's medical issues/concerns and any special instructions related to these issues.
I authorize Capitol Hill Assembly to administer emergency medical care should it become necessary, understanding that I will be contacted immediately in such an event. In the event that someone cannot be reached, I hereby authorize a church representative to secure proper treatment necessary for my child named above. I accept responsibility for payment of expenses incurred as a result of medical treatment.
I hereby release Capitol Hill Assembly and all its participants from any liability or damage to or loss of personal property, sickness, or injury from whatever source which might occur while attending this event.
By attending this event, I give Capitol Hill Assembly permission to use my child's image on the church's social media, website, videos, and other media, knowing that all media is used for promotional purposes only.