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2021 VBS Child Registration

  • Childs NameAge 
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  • LIABILITY RELEASE: In consideration of Resurgent Church allowing the above child(ren) to participate in Vacation Bible School activities, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless Resurgent Church, its directors, employees, volunteers, and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above child(ren) while involved in Vacation Bible School. Furthermore, on behalf of my minor child(ren), I hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in activities involved therein.

    MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) pursuant to this authorization.
  • I DO / DO NOT (Check One) give my consent to Resurgent Church to use photo or video images taken of my child(ren) in church brochures, advertisements for the church, on the website, in social media, and in other church publications as they see fit. I agree to hold harmless Resurgent Church from any liability which may result from the use of said picture(s). This form will apply throughout my child(ren)’s tenure at Resurgent Church’s Vacation Bible School. **None of the photos will be for personal use.** 2021 Vacation Bible School Registration and Waiver Release Form (page 2) I hereby give permission for my child(ren) to participate in Vacation Bible School at Resurgent Church on June 25th 6-8:30pm, June 26th 2-4:30pm, and June 27th 10am-12:30pm.
  • Child’s NameMedical Insurance (YES or NO)Insurance CompanyPolicy/Group ID #Allergies, Medications, and/or Medical ConditionsActivity restrictions 
    Please click the "+" to register additional children
  • Date Format: MM slash DD slash YYYY