Child's Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Parent or Guardian *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact *

Person to be contacted if Parents cannot be reached.

First Name

Last Name

Phone *

(###)

###

####

2nd Child's Name

First Name

Last Name

2nd Child's Birthday

MM

DD

YYYY

3rd Child's Name

First Name

Last Name

3rd Child's Birthday

MM

DD

YYYY

4th Child's Name

First Name

Last Name

4th Child's Birthday

MM

DD

YYYY

Authorization & Release of Liability/Emergency Medical Consent *

I, my heirs, and administrators, and assigns, waive any and all rights and claims of any nature I may have against Meadowlark Church and any of their staff or organization connected with any of the events, their representatives, successors, and assigns for any and all injuries or damages of any nature which I may suffer while taking part in any event. I will assume all risks of any kind that may befall on me or any other person as a result of my or my children's participation in any event. This waiver and release which includes all claims, demands, costs, losses, damages, attorney's fees and liabilities shall be binding on my heirs, administrators and assigns and run in favor of Meadowlark Church. I authorize Meadowlark Church to call 911 in the case of medical emergency for my child and understand that when all attempts to reach emergency contacts are unsuccessful, consent to any deemed necessary examination, medical diagnosis or treatment and hospital care which is rendered under supervision of any physician licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital. Further, as parent/guardian of the minors named above, do hereby consent that my child receive emergency medical treatment by 911 first responders/paramedics without the necessity of first notifying me, and do further agree to hold blameless Meadowlark Church, any physician, hospital or other medical facility. I give permission for my child/children to be photographed and/or recorded during MCC events, including Vacation Bible School (VBS), and understand the images may be displayed in various media formats including website, social media, brochures, and other similar media for outreach and other ministry purposes for no compensation of any kind.

Check the box to AGREE

Home Church *

Please check best description of your family

Members of Meadowlark Church

Regular attenders of Meadowlark Church

Regular attenders of another church

Looking for a home church for my family

Do not attend any church

How did you hear about our VBS program? *

Please select any that apply. Thank you!

My Kids attended last year

Past participation

A friend told me about it

Facebook AD

Email sent to me

A friend forwarded an email to me

Found on church website

Internet search

Community Flyer

Church announcement