2022 Vacation Bible School Registration- Passport to Peace

Child's Name

Child's Birthday

Grade Child just completed

Parent/Guardian Name

Parent/Guardian email

This address will receive a confirmation email

Parent/Guardian Work/Cell Phone

Address (physical address of child/family)

I give consent for any photos of my child taken during VBS to be used in media and publications such as the Arkive and Ark & Dove website. YES NO

Emergency Contact Name

Emergency Contact Phone

Please list any allergy, dietary or medical concerns

I hereby understand that my child will be supervised and that if a health problem or injury arises, I will be notified. If I cannot be reached by phone, medical treatment and/or hospital care will be administered by competent medical personnel including medication, injections, anesthesia, surgery, or other proper treatments and necessary information may be released for insurance purposes. I verify that all health issues are so noted on this form.

YES NO

LIABILITY RELEASE: In consideration of Ark and Dove 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 Ark and Dove, 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.

YES

COVID WAIVER: For Vacation Bible School participation during the COVID-19 virus epidemic, I also voluntarily accept, acknowledge my agreement, and will follow, as parent or guardian on behalf of myself and my child, the following conditions or requirements: 1. Based on the COVID-19 virus, I verify that neither myself nor my child is showing any symptoms of COVID-19, including cough, shortness of breath or difficulty breathing, or at least two of the following: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell. I accept, agree and acknowledge that if my child develops these or other related symptoms during the program, or I or my child or anyone in the child’s household tests positive for COVID-19, my child may not be able to further participate and that the AAC Health Department will be consulted.

YES

2. I agree to provide the child with an appropriately fitting facemask and or use one provided for them by Ark and Dove, which he or she will wear inside at all required times while participating in Vacation Bible School. If policies about masking change participants will be notified of the change via email.

YES

3. I accept, acknowledge and understand that Ark and Dove and Ark and Dove staff will, to the best of their ability, require and enforce all applicable requirements which may assist in offering protection from the COVID-19 epidemic, as specified in the attached Center for Disease Control guidelines, including but not limited to social distancing, sharing of supplies, crafts and equipment, and cleaning and hand washing, but understand the atmosphere of the program may not allow perfect enforcement and assume the risk participation and waive and release the Church, its agents, servants, and employees, from all claims and liabilities of any kind related to that participation or any requirement imposed as the Ark and Dove staff makes their best efforts to comply with the attached guidelines.

YES

I acknowledge that the information I provided on this form is accurate, to the best of my knowledge:

YES

To offset the cost of this program a suggested donation of $5 per child is recommended.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2022 Vacation Bible School Registration- Passport to Peace

Description

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