(574) 674-5918
• 58343 S Apple Rd, Osceola IN 46561 • info@osceolagrace.net
Home
Our Ministries
Grace Students
>
Grace Teen Student Registration
Life Groups
>
Life Group Signup
Contact Us
Calendar
Messages
About Us
>
New Here?
Who We Are
>
Our Story
Staff & Leadership
What We Believe
What To Expect
Grace Kids
>
Grace Kids Lessons
Grace Teen Student Registration Form
*
Indicates required field
Parent Name
*
First
Last
# of students 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
*
Main 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 don't answer.
Emergency Contact Name
*
First
Last
Relationship to the Student:
*
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 #1 mm/dd/yy
*
Current Grade #1
*
[select current grade]
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Gender
*
Male
Female
Age
*
Food/Drug Allergies
*
Child's Name #2
*
First
Last
Birth Date #2 [mm/dd/yy]
*
Current Grade #2
*
[select current grade]
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Gender
*
Male
Female
Age
*
Food/Drug Allergies
*
Child's Name #3
*
First
Last
Birth Date #3 mm/dd/yy
*
Current Grade #3
*
[select current grade]
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Gender
*
Male
Female
Age
*
Food/Drug Allergies
*
Child's Name #4
*
First
Last
Birth Date #4 [mm/dd/yy]
*
Current Grade #4
*
[select current grade]
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Gender
*
Male
Female
Age
*
Food/Drug Allergies
*
Bus Information
Free Bus service is available for selected areas (call 574.674.5918) for Pick-Up areas. Sign up below for bus service.
Select one answer for bus service
*
Yes, we need bus service
No, we do not need bus service
Pick-up address, if different from above
*
Drop off address, if different from above
*
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 Grace Student Ministry activities sponsored by the Osceola Grace Brethren Church for 2017-2018.
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 Student Ministry 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.
Submit
