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VBS is open to rising Kindergarteners through 6th graders. One registration form may be used per family, for up to three children (complete page two if additional children are enrolling). Cost is $10.00 per child, up to a maximum of $25.00 per family.
Please send completed registration form to: Grace Pointe Plainfield, 14210 South U.S. Route 30, Plainfield, IL, 60544, attention: VBS. For additional information, please visit our website at: www.gracepointeplainfield.us. If you have any questions, please contact Karen Yang at 815-715-2706 or [email protected].
Family Information
Family Name: Parent Name(s):
Address: City: Zip: Home Phone:
Cell Phone (mother):
Cell Phone (father):
E-mail Address:
Emergency Contact Information (if parent listed above is not available)
Name: Relationship to Child:
Home Phone: Cell Phone:
Registration and Waiver Information
As parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the following person in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed. In case of a minor, this authority is granted only after a reasonable effort has been made to reach the parent and/or guardian. My signature also serves to indicate my willingness to take full financial responsibility for any and all medical services rendered for the participant(s) named below. My signature also serves to indicate my willingness for my insurance company to be billed for any and all medical fees and services should they be needed, and to release Grace Pointe Church and its employees and its charters from this liability.
Signature of Parent/Guardian: Date:
Child #1 $10.00
Name: Birthdate (mm/dd/yy):
Grade (as of 9/01/14):
Gender: ☐ M ☐ F Medical / Allergy concerns:
T-shirt size: ☐ Youth-S ☐ Youth-M ☐ Youth-L ☐ Adult-M Child #2 $10.00
Name: Birthdate (mm/dd/yy):
Grade (as of 9/01/14):
Gender: ☐ M ☐ F Medical / Allergy concerns:
T-shirt size: ☐ Youth-S ☐ Youth-M ☐ Youth-L ☐ Adult-M Child #3 $5.00
Name: Birthdate (mm/dd/yy):
Grade (as of 9/01/14):
Gender: ☐ M ☐ F Medical / Allergy concerns:
T-shirt size: ☐ Youth-S ☐ Youth-M ☐ Youth-L ☐ Adult-M
VBS Registration Form (March 2014)
June 9 – 13, 2014
VBS Registration Form (March 2014) Page Two
Please send completed registration form to: Grace Pointe Plainfield, 14210 South U.S. Route 30, Plainfield, IL, 60544, attention: VBS. For additional information, please visit our website at: www.gracepointeplainfield.us. If you have any questions, please contact Karen Yang at 815-715-2706 or [email protected].
Child #4 No Charge
Name: Birthdate (mm/dd/yy):
Grade (as of 9/01/14):
Gender: ☐ M ☐ F Medical / Allergy concerns:
T-shirt size: ☐ Youth-S ☐ Youth-M ☐ Youth-L ☐ Adult-M Child #5 No Charge
Name: Birthdate (mm/dd/yy):
Grade (as of 9/01/14):
Gender: ☐ M ☐ F Medical / Allergy concerns:
T-shirt size: ☐ Youth-S ☐ Youth-M ☐ Youth-L ☐ Adult-M Child #6 No Charge
Name: Birthdate (mm/dd/yy):
Grade (as of 9/01/14):
Gender: ☐ M ☐ F Medical / Allergy concerns:
T-shirt size: ☐ Youth-S ☐ Youth-M ☐ Youth-L ☐ Adult-M
