"*" indicates required fields
Parent/Guardian's Name*
Parent/Guardian's Address*
Parent/Guardian's Phone Number*
Parent/Guardian's Email Address*
Emergency Contact Name*
Emergency Contact Phone*
Please make sure that the emergency contact person WILL BE AVAILABLE Sunday Evening.
1st Child
Child's Name
Grade —Please choose an option—Middle School / Jr. HighHigh School
Allergies
2nd Child
3rd Child
I hereby give permission for my youth to attend Valley Bible Church Kingdom Youth Club I hereby release Valley Bible Church, Pacific, WA, their staff, leaders, and volunteers from any and all claims and liabilities of whatsoever nature both individually and collectively that may arise from my youth's participation in the Kingdom Youth Club program and activities. I further agree that Valley Bible Church representatives are authorized to seek such medical, dental, surgical care, or treatment as may be necessary for my youth during his/her participation in the Kingdom Youth Club
(*) Denotes required fields
