BKCC VBS Registration Form

Please register to attend our 2017 BKCC VBS!

* Indicates required field

Name *

First

Last

* *

Male Female

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Last Grade Completed *

DIAGNOSISE5 & MEDICAL CONDITIONS (list medications): *

PARENT OR GUARDIAN Name *

First

Last

Cell Phone Number *

Other Phone Number *

Email *

Please Select *

Yes, I give permission for my child to be photographed or videotaped as part of BKCC activities. I recognize that his or her image may appear in a church or community publication. No, I do not give permission for my child to be photographed or videotaped. I acknowledge that I am the parent or guardian having legal custody of this (these) above listed child (children), a minor(s), ages (as listed), born on the above date (dates), who is (are), with my permission, enrolled in Bent Knee Cowboy Church ("First Church") Vacation Bible School (the "Program"). I hereby authorize the Director of Christian Education of BKCC or any other adult acting as an agent or representative of First Church to take any and all actions that may be necessary or proper to provide for, or arrange for the provision of, the health care of such minor, including, but not limited to, (i) providing for such health care at any hospital or other institution, or employing any physician, dentist, nurse, or other person for such health care, and (ii) consenting to and authorizing any health care, including but not limited to the administration of anesthesia, the taking of X-rays, the performance of tests and operations, and other procedures, by physicians, dentists, nurses, and other medical personnel. I agree to be responsible for any and all charges incurred in connection with any care or treatment rendered pursuant to this authorization, even if an employee, agent or representative of First Church has signed documentation promising to pay for such care or treatment.On behalf of the minor listed above, the minor's parents and/or legal guardians, I agree to defend, hold harmless, indemnify and release First Church and its officers, trustees, employees, agents, representatives, volunteers, and all others who are involved in the Program from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from such minor's participation in the Program. This release includes claims based on the negligence of First Church and its officers, trustees, employees, agents, representatives, and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence.

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