Grace Bible Church - CA - 95747

June 10th - 14th

9:00am - 12:00pm

For: ages PreK through 5th Grade
Location: Grace Bible Church
1390 Baseline Rd
Roseville, CA 95747

Life in the Wild VBS

Join us this summer for an exciting week of adventure as we explore Life In The Wild.
Bring a friend or neighbor to enjoy water slides, arts and crafts, games, singing, and the opportunity to make new friends!
Don't forget to register below to reserve your spot. See you June 10th through the 14th.

Child's First Name

Child's Last Name

Gender

Birthdate

Address of Residence

Apartment, suite, etc.

City

State

Zip/Postal Code

Child's Home Phone

The Child Lives With

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Cell Phone

An alternative number to reach you during program hours

Parent/Guardian Email

Emergency Contact #1

First Name

Last Name

Phone Number

Relation to the child

Please list anyone else permitted to pick up your child

Medical Release Information

Child's Name

Policy Number

Name of Health Insurance Provider

Primary Physician

Phone

Address

Hospital Preference

Please list any medical issues, including any requiring maintenance medication (I.e., Diabetes, Asthma, Seizures). List none if this does not apply to your child.

Is your child being treated for an injury or sickness or taking any medication for any reason?

Yes

If yes, explain

Does your child have any food allergies?

Yes

If yes, explain

Signature Needed

Grace Bible Church Roseville and Life In The Wild summer camp and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child cannot participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e., EMT, First Responder, and/or Physician)

Guardian Name Printed (signature)

Date Signed

Photo Release

I hereby permit my child to be photographed during Life In the Wild by Grace Bible Church Roseville. I understand the photos will be used to keep a journal of activities, to share during PowerPoint presentations and reports, and for promotional purposes, including flyers, brochures, newspapers, and on the internet. I understand that although my child’s photograph may be used for advertising, their identity will not be disclosed. I do not expect compensation, and all photos are the property of Grace Bible Church Roseville and its affiliates.

Parent's/Guardians Initials

Date Agreed for Photo Release

Participation Consent Form

I, the undersigned*, herby release discharge, indemnify, hold harmless and defend Grace Bible Church Roseville and Life In The Wild, its officers, employees, and servants from any and all liability (claims, demands, losses, causes of action, suits, judgments) of any kind that my family or I may have against Grace Bible Church Roseville due to death, personal injury or illness, loss or damage to property, or future causes that occur during the 2024 Grace Bible Church Roseville Life In The Wild summer camp In the event of any medical emergency, I authorize and consent for Grace Bible Church Roseville to act on behalf for medical care deemed necessary for the participant.

Parent's/Guardians Initials

Date Agreed for Photo Release

Payment

The summer camp fee is due at the time of booking. This fee is paid either by cash, check, or card. If a camper’s tuition is unpaid, they cannot attend camp. Payment must be received by 6/1/2024.

< Back

Next >

Submit

For Billing Information please click on VBS Payment below to open the window.
Then click on Register Now Button.