First and Last Name of person completing registration *
Email Address for confirmation of registration *
Child 1 name *
Birthdate *
Grade as of fall 2012 *
Gender *
Registering for: *
Special needs/allergies/health concerns:
Child 2 name
Birthdate
Grade as of fall 2012
Gender
Registering for:
Special needs/allergies/health concerns:
Child 3 name
Birthdate
Grade as of fall 2012
Gender
Registering for:
Special needs/allergies/health concerns:
Would you like one-on-one assistance for your child(ren) from a Special Needs Buddy?
Parent/Guardian name(s) *
Emergency phone *
Has any of the following changed since you last filled out a Lord of Life registration, or is this your first Lord of Life registration? * If yes, please complete the appropriate questions below.
Street address
City, state, zip
Home phone
Parent/Guardian 1 name
Parent/Guardian 1 cell phone
Parent/Guardian 1 email
Parent/Guardian 2 name
Parent/Guardian 2 cell phone
Parent/Guardian 2 email
Permission Section Release from liability: Guardians hereby authorize my son/daughter to participate in said activity. Guardians hereby release, forever discharge and agree to hold harmless, Lord of Life Lutheran Church, from the described event, and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the described event. The undersigned further hereby agrees to hold harmless and indemnify Lord of Life Lutheran Church, its directors, employees and agents for liability sustained by said acts of said participant, including any expenses incurred. *
Medical release: The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify Lord of Life Lutheran Church, its directors, employees and agents from any acts of misconduct, and/or failure to act on the part of those chosen to administer medical aid on behalf of the participant. *
Volunteer opportunities for Elementary VBS
If providing lunch (bring to church), please select a date for your week of VBS:
If providing dinner, please select a date for your week of VBS:
Registration is not complete without payment. Cost is $45 for Elementary VBS. You will be brought to the e-pay page when you click submit. Please select the correct quantity when placing items in your cart. Scholarships are available. Please contact Pastor Todd at todd@lordoflife.org
