Pella Lutheran Church

Vacation Bible School



Vacation Bible School

June 16-18, 2019

6:00 p.m. - 8:00 p.m.


(One form per child, please)

*Student First Name: _________________________________________________________   

*Student Last Name:  _________________________________________________________   

Nick Name: _________________________________                   

Age:  ______________________________________                             

Gender:  Male    Female                            Grade entering: _____________________________    

Home Church (if applicable): ___________________________________________________

Allergies: __________________________________________________________________

Medical Issues or Special Needs: ________________________________________________     

It would be nice if my child is placed in same group as (child's name): __________________       

*Parent Name: ______________________________________________________________   

*Address: ________________________________________________________________________  

*City: _____________________________________________________________________


*Zip: ______________________________________________________________________  

*Email: ____________________________________________________________________ 

*Home Phone Number:_______________________________________________________      

Cell Phone Number:__________________________________________________________    

Emergency Contact: _________________________________________________________

Emergency Phone: __________________________________________________________

Alternate Pickup Name: ______________________________________________________

Alternate Pickup Phone: ______________________________________________________  

General Information: ________________________________________________________           

Medical Release: I give my permission for the VBS staff to administer basic first aid to my child (named above) in the event of an injury. I understand that the VBS staff will contact emergency services in the event of a significant injury and all expenses for such emergency services will be paid by me.

Photo Release: I hereby grant the Pella Lutheran Church permission to copyright and use photographs/videos taken at VBS of the minor designated above in any manner or form for any purpose lawful at any time. I waive any right that I may have to inspect or approve the finished product or written copy, that may be used in conjunction therewith, or the use to which it may be applied.

Permission to Attend: I give permission for my child (named above) to attend the Vacation Bible School (VBS) listed above. I understand that the information I give for this registration will only be used by the VBS hosting church, and that all registration information will be removed from the hosting site by December 31 of this year.


Parent Signature                                                                                              Date