Rome: Paul and the Underground Chuch
VBS 2017

Church of the Palms
July 17-20

Ages 4 and up!
Parents encouraged to participate too (required for any kid 12 or older.)

Dinner 5:30 - 6 p.m.
Rome Okatie 6 - 8 p.m.

Please provide the primary contact information below:

Parent/Guardian First Name(*)
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Parent/Guardian Last Name(*)
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Address(*)
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City(*)
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State(*)
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Zip(*)
Format 29909

Email(*)
Please enter valid email

Primary_Phone(*)
Format 123-456-7890

Please complete the following information for each participant including any and all adults. Cost is $5 per participant with a maximum of $20 for families of 5 or more.

Participant #1 First & Last Name(*)
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Participant #1 age (if not adult)(*)
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Participant #2 First & Last Name
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Participant #2 age (if not adult)
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Participant #3 First & Last Name
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Participant #3 age (if not adult)
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Participant #4 First & Last Name
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Participant #4 age (if not adult)
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Participant #5 First & Last Name
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Participant #5 age (if not adult)
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Special Needs / Allergies
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Please indicate your consent to the following permissions and agreements

Requested Donation
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I understand there is a requested donation of $5/ participant payable on the first night of attendance

Permission to use photos
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See release on left side

Agree To Liability Waiver
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See waiver on left side

If no adult is participating with the child, please provide the following emergency contact information.

Emergency Contact
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Emergency Phone
Format 123-456-7890

Person Allowed to Pickup
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Their Phone Number
Format 123-456-7890

Relationship to Child
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Comments
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