(574) 674-5918
• 58343 S Apple Rd, Osceola IN 46561 • info@osceolagrace.net
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Family Night Registration
family night Registration Form -
(nursery through adults)
masks are required upon entry
*
Indicates required field
Parent Name
*
First
Last
# of kids to register
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Additional Authorized Persons to pick up your child
*
Fill in names of any other people you authorize to pick up your child after VBS each day.
Email
*
Phone Number
*
Home or Cell - whichever is the best place to reach you!
Alt. Emergency Phone must be different than Main Phone Number
Alt. Emergency Phone #
*
Not the same number as above - This is to reach someone if you do NOT answer.
Emergency Contact Name
*
First
Last
Relationship to the Child:
*
If not attending a church enter N/A
Do any of the children you are registering have any special needs?
*
Yes
No
If you answer yes to this question, someone from the VBS staff will contact you to discuss our options of assisting your child.
If "Yes", please explain here
*
Please explain your child's special needs or IEP expectations. Thank-you for helping us know how to best serve your child.
Child's Name #1
*
First
Last
Birth Date [mm/dd/yy]
*
Grade
*
[select grade]
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Teen (7th-12th)
nursery
preschool
Gender
*
Male
Female
Age
*
Select one Activity
*
(select one activity)
Nerf Club (k-6th)
Football Camp (3rd-6th)
Arts & Crafts Club (K-6th)
Axis Teen Talks (7th-12th)
Preschool (3 & 4 yrs old)
nursery & toddler
Child's Name #2
*
First
Last
Birth Date [mm/dd/yy]
*
Grade
*
[select grade]
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Teen (7th-12th)
nursery
preschool
Gender
*
Male
Female
Age
*
Select one activity
*
(select one activity)
Nerf Club (k-6th)
Football Camp ((3rd-6th)
Arts & Crafts (k-6th)
Axis Teen Talks (7th-12th gr)
Preschool (3 & 4 yrs. old)
Nursery & Toddler
Child's Name #3
*
First
Last
Birth Date [mm/dd/yy]
*
Grade
*
[select grade]
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Teen (7th-12th)
nursery
preschool
Gender
*
Male
Female
Age
*
Select One Activity
*
(Select one activity)
Nerf Club (k-6th)
Football Camp (3rd-6th)
Arts & Crafts (k-6th)
Axis Teen Talks (7th-12th)
Preschool ( 3 & 4 yrs. old)
Nursery & Toddler
Child's Name #4
*
First
Last
Birth Date [mm/dd/yy]
*
Grade
*
[select grade]
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Teen (7th-12th)
nursery
preschool
Gender
*
Male
Female
Age
*
Select One Activity
*
(Select one activity)
Nerf Club (k-6th)
Football Camp (3rd-6th)
Arts & Crafts (k-6th)
Axis Teen Talks (7th-12th)
Preschool (3 & 4 yrs. old)
Nursery & Toddler
Parent Name (for elective)
*
Select One Elective
*
(Select elective)
Ladies' Take-a-Break
Basic Firearms Course
Parent Name (for elective)
*
Select One Elective
*
(Select elective)
Ladies' Take-a-Break
Basic Firearms Course
Bus Information
Free transportation is available in the Jimtown school district.
If you need transportation, please check here:
*
Yes (we will call to make arrangements)
Parental Consent Form
The undersigned does hereby give permission for the children listed on this electronic form to attend, ride the bus and participate in Family Night activities sponsored by the Osceola Grace Church for 2021.
Authorization
I understand that in the event medical intervention is needed every attempt will be made to contact the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.
I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Osceola Grace Church through its accident policy will be used as a backup for what my family’s insurance does not cover.
I understand all reasonable safety precautions will be taken at all times by the Grace Kids children’s staff. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Osceola Grace Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
By submitting this form I agree to the above authorization.
I agree!