WVCAC VBS Registration Form (Rev 1.5)

Vacation Bible School for Children age 5 to 12

June 26 Monday to June 30 Friday 9:30am - 12:30pm

Deadline for registraton: June 16,2023

2023 VBS REGISTRATION FORM(One student per form)

West Valley Christian Alliance Church 3003 Moorpark Ave, San Jose, CA. 95128

For registration form and questions, please mail to: office@wv-cac.org or call 408-244-9925

First Name

Last Name

Birthday

Age (By 6/23/2023)

Grade

Gender

Address

City

State

Zip Code

Contact Phone Number

Are you currently attending church?

Yes

Church Name Attended

T-Shirt Youth Size

Siblings in VBS (Name & Grade)

Parentals/Guardian Day Time Phone Number

Parent's/Guardian's Name

Phone/Mobile

Email Address

Relationship

Emergency Contact Name

Emergency Phone/Mobile

Relationship

Other Emergency Contacts

Medical Information

Allergy?

Other Medical Concerns

Physician Name

Physician Phone Number

Medical Insurance

NO FEE: Free of charge but donation is appreciated.

Donate through church website: www.wvalliance.org/donation

How did you hear about our VBS?

Attend WVCAC Programs

Introduce by someone

Visited our website

Other

Release of Liability:

I, the undersigned, parent/guardian of the child mentioned in this form do agree to release and hold West Valley Christian Alliance Church (WVCAC) and it's staffs and teachers harmless from any claim, demand or cause of action for injury to the above named participant(s) of WVCAC's children's programs or damage to his or her personal property which arises out of or is in any way connected with the program of WVCAC.

WVCAC will not be responsible in case of accident, illness or property damage. I also authorize WVCAC to put my child under the treatment of the below-mentioned physician when my child is in medical need. If my child's physician cannot be connected, I agree that my child be treated by any licensed physicians.

I also understand WVCAC may photograph or videotape the events or activities in which I am (or my child is) participating. I give my permission for WVCAC to use photographs or videotape of me (or my child) for the purpose of promoting its services/programs. I give my permission with the following understanding: No compensation of any kind will be paid to me (or my child) at the time or in the future for the use of my (or my child's) likeness, i.e. my child's name on the video.

Type your name in the box as signature

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