Camp Heartwood Vacation Bible School Enrollment
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.
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