June 13-16 • 9am until noon for children who turn 3 by August 15th through completed 5th grade VBS Registration Name* Address Email* Phone Number* Child 1 Name* Child 1 Last Grade Completed* Child 1 Medical Information/Special Needs Child 2 Name Child 2 Last Grade Completed Child 2 Medical Information/Special Needs Child 3 Name Child 3 Last Grade Completed Child 3 Medical Information/Special Needs Please list two people who have permission to pick your child up. Liability Release Form By marking this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to my child/children or our personal property associated with Central Baptist Church Vacation Bible School and events organized by Central Baptist Church. I understand and confirm that by marking this WAIVER AND RELEASE I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this waiver. Photo/Publicity Release I grant Central Baptist Church, its nominees, agents, and assigns unlimited permission to copyright and use, publish, and republish for purposes of advertising, public relations, trade, or any other lawful use, information about me and reproductions of my likeness (photographic or otherwise), whether or not related to any affiliation with Vacation Bible School, with or without my name. I hereby waive any right that I may have to inspect or approve the copy and/or finished product or products that may be used in connection therewith or the use to which it may be applied. I consent and agree, individually and, as parent or legal guardian of the minor(s) named above, to the foregoing terms and provisions. I hereby warrant that I am of full age and have every right to contract for the minor(s) in the above regard. I state further that I have read the above information release and that I am fully familiar with the contents. Signature* Liability Release - Yes Photo Release - Yes NO CAPTCHANameThis field is for validation purposes and should be left unchanged.