Scuba VBS Registration 2024

Scuba VBS by Valley Kids will take place June 9th-June 13th from 6:00-8:15 pm each night at Valley Mills Christian Church (5555 Kentucky Avenue, Indianapolis). Children who are 3 years old (and potty trained) by June 1st through those entering 6th Grade in 2024-2025 school year may register. There is no charge for VBS, but donations are welcome to help offset the costs of programming. Contact the church office at 317-856-3766 if you need registration help.

NOTE: Please see more important details for VBS Week in your confirmation email you'll receive after registering your child.

You may register up to 4 children per form.

Child 1 name (first and last)

Child 1 age or grade in fall of 24'

Child 1 date of birth

Any special needs or accomodation(s) for the child/children (please include food allergies):

Child 2 name (first and last)

Child 2 age or grade in fall of 24'

Child 2 date of birth

Any special needs or accomodation(s) for the child/children (please include food allergies):

Child 3 name (first and last)

Child 3 age or grade in fall of 24'

Child 3 date of birth

Any special needs or accomodation(s) for the child/children (please include food allergies):

Child 4 (first and last)

Child 4 age or grade in fall of 24'

Child 4 date of birth

Any special needs or accomodation(s) for the child/children (please include food allergies):

Parent(s)/Guardian name(s)

This address will receive a confirmation email

Mobile Phone

Address

MEDICAL RELEASE: I, the undersigned parent or guardian of the above noted minor(s), do hereby authorize adult workers with Valley Mills Christian Church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as a parent or guardian of the minor(s) named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for regarding such services. If my son/daughter is feeling ill or are showing ANY signs or symptoms of sickness, they will not attend this event. I also acknowledge that my son/daughter may have a temperature screening prior to and/or during this event. I agree to hold harmless Valley Mills Christian Church (staff and volunteers) from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss or death from or related to COVID-19. My electronic signature confirms that I hereby give witness to the proper completion of this form by the minor's parent or guardian.

PHOTO RELEASE: I understand that photos and video of each event may be taken to further promote future activities for Valley Mills Christian Church. By signing your electronic signature below you grant permission for the image, photo, video, or likeness of those named to be used by Valley Mills Christian Church and posted on the church website or other social media accounts.

Emergency Contact Name:

Emergency Contact Phone Number:

List all names of those authorized to pick up your child(ren):

Optional donation

How did you hear about our VBS?

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 9-13 from 6:00-8:15 PM

Scuba VBS Participant Registration 2024

Scuba VBS Registration 2024

Description

Please Fix the Following