The Queen of Heaven Express
is leaving the station!
Mysteries & Messages
Revealed at Each Stop!
Discover how Mary brings us
closer to Jesus through the
POWER of the ROSARY.
Get Your GOLDEN TICKET
& Track Mary All Over the World!
DATES: JUNE 5TH-9TH
TIMES: 9:00AM – 12:00PM _______
LOCATION: Eberly Farms
Ages: 4 years old (by this summer) -4th Grade
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Child’s Name: (one child per form & print clearly )___________________________________
Sex: F or M
Age: _________
Address:____________________________________________________________________
Email: _____________________________________________________________________
Phone & Emergency Numbers:__________________________________________________
City: ____________________ State: _____ Zip: _________
Other siblings & grades attending VBS:_____________________________________________
Grade (or preschool) for the 2017-2018 school year: __________________________________
T-shirt size (please circle one) Youth: XS SM MED LG XL Adult Sizes: S M
Registration fee per child $45.00 (If your family is need of a financial scholarship please contact Fr. Orr
ASAP) Please make checks out to SEAS.
Please list any food allergies here :_________________________________________________
Please put VBS complete forms in the SEAS Church office in the VBS Box. VBS Registration closes on
April 10th, 2017. If your form is late DO NOT leave it in the office. Please email and ask if forms are still
being accepted along with a late fee.
Contact: Shelly Maldonado- Coordinator. [email protected]
I understand that reasonable precautions will be taken to safeguard the health and well being of the participants in this
VBS and that I will be notified as soon as possible in the event of an emergency. In the case of sickness or an accident, I
authorize and consent the VBS Team, or other associated volunteers of the VBS program to obtain medical care from a
licensed physician, hospital, or medical clinic for my son/daughter in the event that myself or other legal guardian(s)
cannot be reached. I hereby do release and forever discharge this Diocese, and Parish from all manners of actions, claims
which I or the child named above shall or may have for any reason, arising during my child’s attendance of the VBS.
Unless other written instruction is submitted, I also consent to allowing my child’s image to be recorded, either by
photograph or video, and used during the VBS week or for future advertisement of Parish VBS programs. Any other use
will require your further consent.
Parent/Guardian Signature _________________________________
Date________________