Vacation Bible School

Juniata United Methodist Church
Vacation Bible School 2023
August 11th - 15th
6 - 8 PM
814-942-6065

* Indicates required field

This Parental Consent Form gives permission for my child to participate in an activity sponsored by a local church, cluster, district or the Susquehanna Conference of the United Methodist Church. (All portions of this form shall be completed for registration.) It also gives permission for media release and medical treatment: (in the event of an emergency). *

Name of Child *

First

Last

I give my child,

Name of Child *

First

Last

to attend and participate in Vacation Bible School (Stellar) to be held at Juniata United Methodist Church on Sunday, August 11 - 15, 2023 from 6:00 PM until 8:00PM. *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Type of Allergies and or other (please specify) *

Does your child require any special accommodations or have special accessibility needs? Explain. *

Media Release I give my permission for photographs or other electronic images of my child to be used at the discretion of Juniata United Methodist Church on Facebook, website, newsletter, worship (projection on screen), etc. Medical Treatment Release and Liability Release In the event of an emergency, I hereby authorize event staff to obtain and give consent for medical treatment for my child for such injury or illness that may occur during the event, and hereby hold the event staff and their representatives harmless in the exercise of this authority It is my understanding that the above named participant will be covered by my personal medical insurance. The event provides limited/supplemental medical payment coverage for injuries arising out of the event activities which is payable in excess of any other collectable insurance. Payments of any medical injuries not covered by my insurance or the event limited/supplemental medical insurance will be paid by me. *

Parent's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Telephone Number *

Work Telephone Number *

Email *

Medical Insurance Carrier and Group Number *

This form is made available by the Property, Casualty, Directors and Officers Insurance Committee of the Susquehanna Conference of the United Methodist Church and may be copied. Approved by Conference Chancellor, Conference Trustees and Property, Casualty, Directors and Officers

Form date 5/2001 Updated 4/30/2024

Submit

Juniata United Methodist ChurchVacation Bible School 2023 August 11th - 15th6 - 8 PM​814-942-6065

Juniata United Methodist Church
Vacation Bible School 2023
August 11th - 15th
6 - 8 PM
814-942-6065