Vacation Bible Camp Registration

Child’s full name*

Sex*

Male

Female

Birth date*

Grade going into fall 2025*

Parents’/guardians’ full names*

Address*

City, State*

Zip*

Email*

Emergency contact*

Relationship to child*

Emergency contact #*

Alternate #

Name and city of home church

Dietary restrictions *

Yes

No

If YES, please list/explain

Medical concerns*

Yes

No

If YES, please list/explain

Names of people authorized to pick up my child*

Please check the box next to the following items to indicate your consent to each and print your name (as signature) and date below.

I consent to allow Light of the Hills and its VBC staff to give my child(ren) medical care in the event of a medical emergency and trust that medical professionals will be contacted in addition to myself. *

I give my permission for any photos, videos, or quotes taken of my child to be used for Light of the Hills’ children’s ministry publicity, including but not limited to the church’s website, newsletters, brochures, social media, and promotional videos.

I release, discharge and hold harmless Light of the Hills Lutheran Church, its staff, officers, and agents, from all liability and loss (including court costs and attorney fees), resulting from any property damage, personal injury and bodily injury including death, to my child, which is caused or claimed to be caused, in whole or in part by the negligent acts or omissions of Light of the Hills Lutheran Church, its staff, officers, and agents.*

Parent’s printed name as signature*

Date*

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