VBS 2025 Registration — Montague Baptist Church

Child's Full Name

Child's Grade Completed

Child's Age

Child's Date of Birth

Parent/Guardians Name(s)

Email address

Home Phone

Mobile Phone

Mailing Address

City

State

Zip Code

Emergency Contact Name #1

Emergency Contact #1 Phone

Emergency Contact Name #2

Emergency Contact #2 Phone Number

Doctor

Doctors Phone Number

Asthma

Diabetes

Stomach Issue

Anxiety

Heart Trouble

Physical Handicap

Epilepsy/Seizures

Additional notes/Allergies

Parental Consent, Release, and Indemnification

A. Releasor consents to the participation of Child in the above listed Event and Activities.
B. Releasor certifies that Child is physically and emotionally able to participate in the above listed Event and Activities.
C. Releasor certifies that he/she executes this Release freely, voluntarily, and after sufficient review.
D. Releasor certifies and he/she has the authority to release Church from any and all claims and has not transferred such authority to any other person.
E. Releasor authorizes the agents of Church to make emergency medical decisions on behalf of Child in the event Releasor cannot be reached. Releasor acknowledges that he/she will ultimately be responsible for the cost of any medical care provided to Child.
F. Releasor agrees to release and indemnify the Church, its pastors, trustees, directors, officers, employees, agents, and volunteer workers from any and all liability for injury, loss, or damage to person or property that may occur during the course of the Child’s involvement in the Event.
G. Releasor agrees to attempt to settle all such claims through good faith negotiation with Church. If good faith negotiation fails, Releasor agrees to attempt to settle all such claims through mediation with a professional mediator. If mediation fails, Releasor agrees that the laws of the Commonwealth of Virginia shall govern and the jurisdictional forum shall be the Commonwealth of Virginia.

Relationship to Child

Date signed

SignatureOf Releasor/Permission