Vacation Bible School Registration

VBS will be in session from June 17th to the 21st from 9am to 1pm for ages 4-12! Don't forget to bring your own lunch!
At the end of this application you will be prompted to pay the $40 fee (per child) for the week, please be mindful that your child's spot is not secure until payment is received.

IMPORTANT NOTICE FOR OUR PARENTS/GUARDIANS

Thank you for choosing the House of Restoration Church Vacation Bible School Summer Program for children ages 4-12. We’re looking forward to an awesome summer and can’t wait to start! All the information you will need to register your child is on this sheet. Enrollment is on a first come, first serve basis so register as soon as possible to ensure your child will have a fun filled summer program experience.

The program runs: Monday, June 17, 2024 – Friday, June 21, 2024

HOURS OF OPERATION - Monday through Friday, 9:00 am - 1:00 pm. Children can be dropped off from 8:45am to 9:00am.

APPLICATION - Please complete the full application. It is very important that the form(s) are completely filled out. Please note all information is confidential.

First Name

Last Name

Middle Initial

Birthdate

Gender

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

School Name and City/Town

Grade

Family Setting

Parent/Legal Guardian First and Last Name

Parent/Legal Guardian Address

Parent/Legal Guardian Phone Number

Parent/Legal Guardian Email

Insurance Company Name

Insurance Policy Number

Medications? (please add N/A if none.)

Allergies or Medical Conditions? (please add N/A if none.)

Physician Name

Physician Phone Number

Hospital Name

Hospital Phone Number

Disabilities? (please add N/A if none.)

LIST PERSONS AUTHORIZED TO PICK UP CHILD, OTHER THAN PARENT OR GUARDIAN (please add N/A if none.)

Authorized Pick Up #1 First Name and Last Name

Authorized Pick Up #1 Relationship to Child

Authorized Pick Up #1 Phone Number

Authorized Pick Up #2 First Name and Last Name

Authorized Pick Up #2 Relationship to Child

Authorized Pick Up #2 Phone Number

LIST ANY PERSONS NOT AUTHORIZED TO PICK UP CHILD (if any)

Not Authorized for Pick-Up #1 Name

Brief Description of Not Authorized for Pick-Up #1

Not Authorized for Pick-Up #2 Name

Brief Description of Not Authorized for Pick-Up #2

Not Authorized for Pick-Up #3 Name

Brief Description of Not Authorized for Pick-Up #3

I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the House of Restoration Church of Hartford, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors, interns, or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities at House of Restoration Church of Hartford and/or the Vacation Bible School Programs.

Please Read the Parent Release

I have read the Parent Release.

Please sign that you have read the Parent Release.

I give permission to the House of Restoration Church of Hartford to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment.

Please Read the Medical Treatment

I have read the Medical Treatment.

Please sign that you have read the Medical Treatment.

I understand that the House of Restoration Church is not responsible for lost or stolen items.

Parents and program participants are responsible for their own transportation to and from the program. All parents/legal guardians must sign their child in & out of the program every day.

I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the House of Restoration Church its program and activities.

I also understand that the House of Restoration Church programs are not, nor claim to be, a licensed day care center.

I have read the completed application and this form, understand the rules of the House of Restoration Church and request that my child be admitted into the program.

Please Read the Miscellaneous

I have read the Miscellaneous.

Please sign that you have read the Miscellaneous.

EXPECTATIONS & POLICIES

Please read the following information carefully and sign the bottom of the form. Your signature below indicates that you agree to follow the stated policies.

I understand that my child can be dropped off from 8:45am to 9:00am and no earlier. The designated entrance for the building will be the gymnasium door on the side of the building.

My child MUST be picked up at or before the (1:00pm) designated time. I understand that if this expectation is NOT MET that my child’s participation in the program could be jeopardized.

I hereby agree that all photographs, negatives, prints, paintings, drawings, sketches, reproductions, and likeliness of any kind made of the child are and shall remain the property of the House of Restoration Church Vacation Bible School Summer Program.

I/We understand that in signing this registration, I/We agree to hold House of Restoration Church Vacation Bible School Summer Program, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors, or volunteers, harmless in case of illness, accident or injury, and that our family’s medical plan will cover any expenses. In signing this, I agree to the above expectations and regulations of the House of Restoration Church Vacation Bible School Summer Program.

Parent/Legal Guardian Signature

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Vacation Bible School Registration

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