*Please fill out a separate form for each child
Register for SonSpark Labs VBS!
June 20-24th, 9:00 am to Noon
Indicates required field
Please fill out a separate form for each child.
Last School Grade Completed
Home Church (Optional)
Allergies/Other Medical Conditions
Who has permission to pick up your child?
In Case of Emergency, Contact
Relationship to Child
I give permission for photographs or videos of my child to be used by Hucrest Community Church of God and/or Roseburg Alliance Church for historical and/or promotional purposes including Hucrest Community Church of God and/or Roseburg Alliance Church's print, web, and social media.
Photo Permission Given
Photo Permission Denied
I hereby give my consent to have my minor child participate in the following activity of
Community Church of God in collaboration with Roseburg Alliance Church
: Vacation Bible School (hereafter “the activity”) on or about June 20, 21, 22, 23, and 24, 2016
I recognize that there are risks involved in participating in this activity and hereby assume all risk
of injury, harm, damage, or death to my minor child in connection with his-her participation in
he fullest exten
d by law, I rele
Hucrest Community Church of God and Roseburg Alliance Church, their
nts and repr
ives from any inju
damage or death which may occur to my minor child while participating in the activity and agree
rch of God and Roseburg Alliance Church
, their trus
directors, employees, agents and representatives from any claims arising out of my minor
child's participation in the activity.
Further, being the parent or legal guardian of the minor child, I do consent to any medical,
surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor
child. I understand that ef
forts will be made to contact me prior to treatment but
, in the event I
not be reac
hed in an emergen
, I give permi
n to the acti
r to make the
ry for trea
re be no act
, I gi
on to the atte
cian to treat my minor child. As pare
nt or leg
nd that I am responsible for the health care decisions of my minor child and agree that
nce plan is th
n to pa
r the medi
l, or ho
t that is given to my minor child. Any insu
rance policy of the ch
urch or organiza
sponsoring this event will be used as the secondary coverage.
I am the child's parent or legal guardian and I have read and agree to the authorization above. FULL NAME BELOW
To sign, please type your full legal name.
By checking 'yes' I certify that I am the child's parent or legal guardian.
No *Please bring a paper copy of the Emergency Form below (signed by parent/legal guardian) prior to VBS
Emergency Consent Form
Hucrest Community Church of God
2075 NW Witherspoon Ave.
Roseburg, Oregon 97471
Office Hours: By Appointment