June 11 - 15, 2017 (Mon. - Fri.)

9 AM - 11:45 AM

Discovery Fellowship Church

6630 Brittany Drive

Fort Collins, CO 80525

970-204-6787

Amped VBS is for children age 4 by June 11, 2018 through entering 5th grade. Groups are arranged by grade. On-line registration closes on Friday, June 8th. After that, walk-in registrations are welcome during the week of VBS

Save & Return Account (optional)

New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish. The account you establish is only for this form.

Participant Information

Child One

Child's first & last name *

Gender *

Birth Date *

Grade Entering - Fall 2017 *

Age as of 6/11/18

Name of one friend to be placed in group (must be same grade as child)

Allergies, Medical issues or none *

Child Two

Child's first & last name

Gender

Birth Date

Grade Entering - Fall 2017

Age as of 6/1/17

Age as of 6/11/18

Name of one friend to be placed in group (must be same grade as child)

Allergies, Medical issues or none

Child Three

Child's first & last name

Gender

Birth Date

Grade Entering - Fall 2017

Age as of 6/1/17

Name of one friend to be placed in group (must be same grade as child)

Allergies, Medical issues or none

Child Four

Child's first & last name

Gender

Birth Date

Grade Entering - Fall 2017

Age as of 6/1/17

Name of one friend to be placed in group (must be same age as child)

Allergies, Medical issues or none

Child Five

Child's first & last name

Gender

Birth Date

Grade Entering - Fall 2017

Age as of 6/1/17

Name of one friend to be placed in group (must be same grade as child)

Allergies, Medical issues or none

Parent/Guardian Information

Father's Name (First & Last)

Cell Phone

E-mail address

Mother's Name (First & Last)

Cell Phone

E-mail address

Home Address

City

State

Zip

Home Church (if applicable)

Emergency Information (other than parent)

Emergency Contact Name

Relationship to Child

Emergency Daytime Phone

Permission from Parents

I recognize that Discovery Fellowship Church uses photographs and video images of events in publicity materials such as the church website, photo walls, and newsletters and I hereby grant permission for photo/video images of my child to be taken and used for such purposes. Please type your name in the box below if you give Discovery Fellowship Church permission to photograph your child during VBS or type no if you do not.

My child may be given basic first aid (bandages, ice pack, etc.) by the Adult Leadership as needed. I authorize treatment, by a qualified and licensed medical doctor, of the minor in the event of any medical emergency which, in the opinion of the attending physician, is necessary and I cannot be reached after reasonable effort has been made to secure my personal consent. Any medical expenses are the responsibility of the participant and their insurance carrier. I, the parent/guardian of the registrant, a minor, recognize the possibility of physical injury associated with Discovery Fellowship Church. Inconsideration for DFC accepting the registrant for its programs and activities, I hereby release, discharge, and/or otherwise indemnify DFC, its employees and associated personnel, including the owners and directors of facilities utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the program. Please type your name in the box below if you agree with these statements or no if you do not agree