CAMP HEARTWOOD VBS REGISTRATION
Child’s Name:__________________________________________________________
Birthdate:________________________ Last grade completed (K-5):_____________
Parent/Guardian___________________________________ Date:________________
Parent/Guardian Phone (h):______________________ Phone (c):_______________________
Address: _____________________________________________________________
Additional Emergency Contact ___________________________________________
Phone (home):_________________ (cell):____________________ (work):_______________
Email address: (optional) __________________________________
Medical Information:
Allergies or medical conditions______________________________________________________________
Medications, dosage, and time to be given:___________________________________________________________________________
Doctors name:__________ Phone#_______________ Medical insurance:_________________
Transportation:
I will transport my child to and from VBS: ___
My child needs transportation: ____
Who has permission to pick your child up?
Name:_________________________________ Relationship:___________________
Name:_________________________________ Relationship:___________________
I am enrolling (child’s name) ______________________ in the Heartwood Vacation Bible School program that
will be held August 10-14 and August 17-21 2015, 8:30am-1:00pm at the Heartwood Center 64 Hartwood
Church Rd., Stafford, VA 22471 and have read the Participation Agreement and acknowledge and accept the
terms within. I give permission for her/him to participate in the activities and be transported by Heartwood
volunteers. In case of medical emergency, I authorize the Heartwood VBS leadership to secure medical
treatment including hospitalization, injection, surgery, and anesthesia.
Signature:______________________________________________
Date:________________________
For additional information please call 540.788.9838 or email
Please send completed registration to: Fredericksburg District UMC P.O. Box 100, Ladysmith, VA 22501 or fax
to 804.448.8328
ACTIVITY PARTICIPATION AGREEMENT
Heartwood Center Vacation Bible School
Activity Sponsor: Heartwood Center
August 10-14 and August 17-21 2015, 8:30am-1:00pm
at Heartwood Center 64 Hartwood Church Rd., Stafford, VA 22471
I acknowledge that participation in the activity described above involves risk to the participant and participant’s
parents or guardians(if participant is a minor) and may result in various types of injury including but not limited
to the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial
damage. In consideration for the opportunity to participate in the activity described above, the participant or
parent/guardian acknowledges and accepts the risks of injury associated with participation and transportation
to and from the activity. The participant or parent/guardian accepts personal financial responsibility for any
injury or other loss sustained during the activity or during transportation to and from the activity as well as for
any medical treatment rendered to the participant that is authorized by the Activity Sponsor (Heartwood
leadership). Further the participant or parent/guardian releases and promises to indemnify, defend, and hold
harmless the Activity Sponsor for any injury arising directly or indirectly out of the described activity or
transportation to and from the activity, whether such injury arises out of the negligence of the Activity Sponsor,
the participant or otherwise. If a dispute over this agreement or any claim for damages arises, the participant
or parent/guardian agrees to resolve the matter through a mutually acceptable alternative dispute resolution
process. If the participant or parent/guardian and the Activity Sponsor cannot agree upon such a process, the
dispute will be submitted to a three member arbitration panel for resolution pursuant to the rules of the
American Arbitration Association.