Vacation Bible School Family Registration Form
June 26 – June 30, 2017, Monday – Friday
9 a.m. to Noon - Ages 4 through Rising 5th graders
Fee: $25.00 for 1 child; $50.00 for 2 or more/ AFTER May 21 $30 PER CHILD
Fee includes one CD per family & covers supplies
Complete One Form Per Family
Return completed forms & payment (check made payable to Holy Family with VBS in memo line) to the drop box
outside Tiffany Watson’s office or parish office by May 21st (registration is first come/first serve basis)
Child 1: Gender (circle one) Male
Female
Child’s Name: _________________________________________________________________________
Child’s Age: _______ Date of Birth: __________ Grade completed as of 6/17: ____________________
Child 2: Gender (circle one) Male
Female
Child’s Name: _________________________________________________________________________
Child’s Age: _______ Date of Birth: __________ Grade completed as of 6/17: _____________________
Child 3: Gender (circle one) Male
Female
Child’s Name: _________________________________________________________________________
Child’s Age: _______ Date of Birth: __________ Grade completed as of 6/17: _____________________
Parent/Guardian Name (s):_______________________________________________________
Street address/city/zip:__________________________________________________________
Telephone (circle Home/Work/Cell):
Primary (H/W/C):______________________ Secondary (H/W/C): ______________________
Email:_______________________________________________________________________
Emergency Contact Name (other than parents):_______________________________________
Contact Number:_______________________ Relationship to child: ______________________
Home parish:_________________________________________________________________
The children will perform VBS songs at Mass 7/1-7/2. Please choose the Mass you will attend:
Saturday 5:30pm ___ Sunday 8:15am ____Sunday 10:30am _____
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If your child would like to be with a friend, please list the name of your child and friend’s name. They need to be
close in age/grade and we cannot guarantee they will be together:
_____________________________________
Holy Family VBS Release 2017
Parish: Church of the Holy Family
Phone: 757-481-5702
Address: 1279 North Great Neck Road City: Virginia Beach
Zip: 23454
Type of Event: see information for each event to be given out separately
Destination: see information for each event to be given out separately
Individual in Charge: Tiffany Watson/Adult Volunteer Catechists
Transportation: see information sheets for each event to be given out separately
Dates of Trip: see information sheets for each event to be given out separately
Does your child have any allergies? __Yes __No
Details – specify child(ren)’s name:
Is your child taking any medication? __Yes __No
Details – specify child(ren)’s name:
Is there any other physical or emotional condition of which we need to be aware? __Yes __No
Please explain – specify child(ren)’s name:
As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor. I
agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the
Catholic Diocese of Richmond, the Church of the Holy Family, their employees and agents, chaperons, or representatives
associated with the event from any claim arising from or in connection with my child attending the event or in connection
with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate
the Diocese and/or Church of the Holy Family, their employees and agents and chaperons, or representatives associated
with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a
result of such injury or damage, unless such claim arises from the negligence of the Diocese and/or Church of the Holy
Family.
I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health
of my child. In the event of any emergency, I hereby give permission to transport my child to a hospital for emergency
medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of
an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to
be notified. I will not hold the Diocese of Richmond and/or the Church of the Holy Family responsible for authorizing any
medical treatment beyond necessary transportation to the hospital.
Parent/Guardian Signature: _____________________________________ Date: ____________
I give permission for pictures and/or video of my child(ren) (named above) engaged in activities related to the Church of
the Holy Family to have their pictures posted in publications or websites. Names of participants will not be used without
expressed permission from the parent or guardian. If no box is checked below, the Church of the Holy Family assumes
you give permission.
__Yes __No
Parent/Guardian Signature: ___________________________________________ Date: ____________
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