VBS 2022 Registration for Participation

Dear KOG Friends and Family,

This Registration Form is for children preschool age (no longer in diapers or pullups) to 6th grade in the fall of 2022.

Fill out one form per child and click submit. Please make note that our registration is non-refundable.

In just a few weeks you will receive an email with more information of dates and times to all of our events leading up to VBS, including the week of VBS.

Please don't hesitate to reach out with any questions or concerns!

Let's make some waves!

Amanda Pulos
Director of Youth and Children's Ministry
kogkids@gmail.com
(714)604-3373

If you are 7th grade through high school or even an adult there is a place for you at VBS too! CLICK HERE FOR VOLUNTEER REGISTRATON!

Child's Name (Minor)

Grade in Fall

Date of Birth

Age

Do you have a home church?

Yes No Other

Where do you worship currently?

Transportation to/ from VBS will be provided by the following people:

The following person/people are NOT to pick up my child from VBS

Parent or Guardian's Contact Information

Parent or Guardian's Name

This address will receive a confirmation email

Phone

Address

In the event of an emergency, in which I am not available, please notify:

Name and Relationship

Phone

Health Information- Please check any that apply and please describe and/or date appropriately:

Does your Child have any health concerns or special needs?

YES NO

If Yes, please explain:

Allergies:

Asthma (Inhaler instructions):

Dietary Restrictions:

Immunizations:

Tetanus MMR TB Diphtheria Polio

Pertinent Health Information:

Child's Health and Accident Insurance Information

Phone Number, Policy Number and Group Number

Minor's Physicians Name and Phone Number

MEDICAL AUTHORIZATION, RELEASE OF LIABILITY AND PERMISSION FORM (For ALL Youth Under The Age Of 18)

MEDICAL RELEASE STATEMENT AND WAIVER

I hereby authorize King of Glory Lutheran Church, into whose care Minor has been entrusted, to consent to medical or dental treatment or care for Minor under Section 6910 of the California Family Code. The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care under the general or special supervision and upon the advice of or to rendered by a physician or surgeon licensed under the Medical Practice Act and to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care by a dentist licensed under the Dental Practice Act. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, and is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment may deem advisable.

I further authorize King of Glory Lutheran Church to receive physical custody of Minor under Section 1283 (a) of the California Health and Safety Code upon completion of any treatment, and I specifically instruct any treating health facility to surrender the physical custody of Minor to King of Glory Lutheran Church of Fountain Valley.

RELEASE OF LIABILITY:

I understand the nature of the events and do hereby release, acquit, and forever discharge, on behalf of myself and Minor, King of Glory Lutheran Church, its sponsors, agents, servants, successors, heirs, executors, and administrators, from any and all claims, actions (or cause of action), or expenses whatsoever, which the undersigned now has or may hereafter accrue on account of or in any way growing out of any known and unknown, foreseen and unforeseen bodily injuries and property damage and the consequences thereof resulting or to result from any accident, casualty or event which has or may occur during activities sponsored by or under the auspices of said King of Glory Lutheran Church.

The authorization is given pursuant to Section 25.8 of the Civil Code of California and remains effective until revoked.

PERMISSION AND AUTHORIZATION TO CONSENT TO TREAT A MINOR: I, ____________________________________am the parent, legal guardian, or the caregiver who is a relative of, and who, under Section 6550 under the California Family Code, may authorize medical and dental care for_____________________________, (Minor's name) I give permission for Minor to take part in any of the events held with King of Glory Lutheran Church.

Parent, legal guardian or caregiver's name

Minor's name

Mother or Legal Guardian's Name:

Address

Phone

Father or Legal Guardian's Name:

Address

Phone

Photo Consent

Photographs may be used for the following items:

KOG page, church marketing materials such as Fountain Valley Living or other local magazines, brochures, flyers, church newsletters, and/or other items to help promote KOG Church and Preschool.

The child's name will never be identified.

By marking yes I consent that photographs of my child and/ or of myself may be used in the above mentioned ways for KOG preschool or church publicity and marketing.

YES NO

By checking I agree I am stating that I have read all of the form above and have provided all of the necessary information.

I Agree

Parent or Guardian's Signature

Date

Registration Payments: On or Before June 27th ($25) After June 27th ($35.00) No refunds

Registration Cost

Payments using cash or check can be made in the Church Office during the week (Mon, Wed. & Fri 9 am- 12:30 pm) or at church on Sundays.

Cash Check Online Other

If Paying Online With A Credit or Debit Card, Enter the Payment Amount Here.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

VBS 2022 Registration for Participation

Description

Please Fix the Following