Northwest Presbyterian 2017 VBS Registration
July 10-14, 2016 9am - noon each day
For children who will be 4 years old by September 1, 2017 through rising 6th grade.
You’re invited to join the fun as students discover the qualities that make them truly HEROES of God!
NWPC is partnering closely with the Jacob’s Ladder team to provide the resources and accommodations necessary to make this an accessible and exciting experience for all – including music, science, crafts, story telling, and recreation!
Date of Birth
Child must be 4 years old by September 1, 2017
Grade entering in Fall 2017, or academic level
Parent or Guardian's Name
Primary Phone Number
Secondary Phone Number
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Are there any allergies, medical conditions, mobility limitations, or special needs that we should be aware of? If so, please list here.
Would your student benefit from any accomodations or modifications to the curriculum ro structure? (Personal shadow, frequent breaks, special grips for art tools, access to quiet rooms, etc.)
List the names of any persons other than parents / guardians who may pick this child up from VBS. Please also give their relationship to the child.
Emergency Contact Name
Emergency Contact Phone Number
A great VBS requires lots of parent volunteers! We would love for you to be involved by helping with snacks, crafts, music, etc. or by being a group guide. Please indicate below how you would be able to help!
I, the parent/guardian of the child named above, a minor, authorize adult workers with Northwest Presbyterian Church to act as my agent(s) to consent to medical care should my child be injured at Vacation Bible School and need medical attention. I assume all financial responsibility for any care provided. I understand that in the event of an emergency, I or my listed emergency contacts will be notified immediately.
In consideration for allowing my child to participate in programs and other activities at or sponsored by the Church and further in consideration of the Church allowing me and my child to enter and use the facilities owned, leased or otherwise provided by the Church (the "Facilities") undersigned, for myself and for my child and his/her parents, heirs, assigns, personal and legal representatives and estate, fully and completely releases, discharges and holds harmless the Church, and its directors, officers, employees, agents, insurers, instructors, caregivers, and volunteers (collectively "its agents and employees") from any and all claims, actions, causes of action, and damages of any kind whatsoever, including but not limited to claims for personal injury or property damage, arising out of my child’s participation in any program or activity at the Church or the Facilities.
The undersigned acknowledges and recognizes there are inherent risks involved in certain activities or recreational activities at the Church and the Facilities and the undersigned and my child assumes the risk of any injury sustained while at the Church or at the Facilities.
The undersigned agrees to indemnify, defend and hold harmless the Church and its agents and employees from any and all claims arising out of my child’s participation in any program or activity at the Church or the Facilities, even if such claim arises as a result of a negligent act or omission of the Church or its agents and employees.
I give consent for my child to be photographed, videotaped or filmed while participating in class activities and for the resulting images to be used by Northwest Presbyterian Church for promotional purposes.
Cost per Child
Do Not Fill This Out