VBS Child Registration Form

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- Number of children registering (ages 4-10)? REQUIRED Please fill out this field.
- Child 1
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 2
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 3
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 4
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 5
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 6
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 7
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 8
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 9
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
- Child 10
  - Full Name REQUIRED Please fill out this field. Please enter valid data.
  - Gender REQUIRED Boy Girl Please fill out this field.
  - Grade entering in Fall 2024 REQUIRED Please fill out this field. Please enter valid data.
  - Age at time of VBS REQUIRED Please fill out this field. Please enter valid data.
  - Allergies/Medications/Other Medical Issues Please enter valid data.
Name of Parent/Guardian #1 REQUIRED Please fill out this field. Please enter valid data.
Best Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter valid data.
Address Please enter valid data.
City Please enter valid data.

State

Zip Please enter a zip code.
Name of Parent/Guardian #2 Please enter valid data.
Best Contact Phone Number Maximum 20 characters Please enter a phone number.
Email Please enter an email address.
Mailing Address Please enter valid data.
City Please enter valid data.

State

Zip Please enter a zip code.
Parish/Church Name Please enter valid data.
Medical Care Information
Primary Care Physician Name Please enter valid data.
Primary Care Physician Phone Number Maximum 20 characters Please enter a phone number.
Name of Health Insurance Please enter valid data.
Policy # Please enter valid data.
Policy Holder Name Please enter valid data.
Emergency Contact Information
Name Please enter valid data.
Relationship Please enter valid data.
Best Contact Phone Number Maximum 20 characters Please enter a phone number.
VOLUNTEERS NEEDED! Please write the name(s) of anyone over 18 in your household who might be willing to volunteer. We will be in touch! Please enter valid data.
I request permission for myself/my child(ren) to attend this event to be held at St. Joseph’s Church. I understand this event will take place under the guidance and supervision of responsible employees/volunteers from the Diocese of Portland and, if needed, give permission for myself /my child(ren) to be evaluated, diagnosed, treated/medicated in accordance with standard medical practice by licensed medical personnel. I relieve the parish, diocese, and volunteer leaders of all responsibility and consequences that may arise because of this treatment. I will not hold the parish, diocese, or representative associated with this event responsible in the event of injury. If I cannot be reached in case of an emergency I give permission for the parish coordinator to act on my behalf. Further, I agree to accept any and all financial responsibility related to such care.

I/my child(ren)agree to abide by all the rules as outlined in the Diocese of Portland Code of Behavior/Ethics.* The Diocese of Portland will not be liable if myself/my child(ren) fail to cooperate with said rules and any infractions may result in immediate dismissal from this event. I understand that I am legally responsible for the behavior of myself/my child(ren).
I Agree Please select this field.
DIGITAL RELEASE: By checking the box below, I hereby grant to the Diocese of Portland my consent without reservation to use, assign, convey, reproduce, copyright or publish my/my child’s name, voice, image, and/or likeness that arises from my/his/her participation in this event, whether still or motion pictures, audio or video tape, for promotional, instructional, business or any other lawful purposes, at the Diocese of Portland’s sole discretion.
Digital Release REQUIRED I agree. I do not agree. Please fill out this field.
We are happy to offer secure online payment through our website provider, eCatholic. If you choose to pay online, the payment screen will appear after you hit 'pay now' on the bottom of this form.

To pay by check, use the 'pay later' option and make it out to "St. Paul the Apostle Parish" and send or drop it off at the parish office, Attn: VBS Coordinator, 217 York St., Bangor, ME 04401.

Please do not let financial limitations keep you from participating--we have scholarships available!
Registration Fee (if paying online)

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VBS Child Registration Form

VBS Child Registration
(ages 4-10)

vacation bible school 2024

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