VBS Camper Registration

- REGISTER TODAY - SPACE IS LIMITED
- We are currently taking registration for this year's VBS Camp! To sign up, please fill out the fields below.
  VBS Dates: Monday, July 13th through Friday, July 17th.
  Time: 8:30 A.M. - 12:00noon
  Location: St. Francis Xavier Parish, 3801 Scott Road, Burbank, CA 91504 Contact: rosie.roope@gmail.com
  Open to: incoming 1st-5th Graders $95/child
  Extended care is available until 3pm - $20/day
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  CAMPER INFORMATION
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Gender REQUIRED Please fill out this field.
  
  School in the Fall REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in the Fall REQUIRED Please fill out this field.
  
  Tee Shirt Size REQUIRED Please fill out this field.
  
  Are you enrolling your child in extended day care to 3 pm? REQUIRED Please fill out this field.
  
  FAMILY INFORMATION
  
  Parent 1: Name REQUIRED Please fill out this field. Please enter valid data.
  
  Parent 1 Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Parent 1 Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent 2: Name Please enter valid data.
  
  Parent 2 Phone Number Maximum 20 characters Please enter a phone number.
  
  Parent 2 Email Please enter an email address.
  
  Secondary Emergency Contact
  
  Name/ Relationship REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  MEDICAL INFORMATION
  
  Camper's Parent/Guardian First & Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Camper REQUIRED Please fill out this field. Please enter valid data.
  
  Camper's Primary Adult Contact during VBS Camper (First & Last Name) REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Camper REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Emergency Contact during VBS Camp if Primary Adult is not available (First & Last Name) REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Camper REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Health Insurance Provider REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Policy # REQUIRED Please fill out this field. Please enter valid data.
  
  Group # REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  List any allergies - medicines, foods, etc. REQUIRED Please fill out this field.
  
  Does your child have any medical or special needs, including medications currently being used? REQUIRED Please fill out this field.
  
  If yes, please explain:
  
  Is your child up to date on immunizations? REQUIRED Please fill out this field.
  
  Camper's Physician's Name: REQUIRED Please fill out this field. Please enter valid data.
  
  Physician's Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Please notify the RE Office if this child is exposed to any communicable diesease during the three weeks prior to attendance.
  
  PERMISSION SLIP/MEDICAL RELEASE
  
  My child has my permission to attend Vacation Bible School at St. Francis Xavier Parish. In the event of illness or injury to my child during their attendance at an activity/meeting, I have provided the St. Francis Xavier Religious Education with the proper emergency contact information, health information describing my child’s medical problems (if any) in full as well as insurance information, and consent in advance to medical treatment. I understand that in the event of a serious illness or injury reasonable efforts to reach me will be attempted.
  
  AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR: I give permission to the responsible staff members, volunteers, medical practitioners and medical facilities to use their judgement in obtaining and providing medical treatment for my son/daughter should it become necessary to do so. I agree to relieve the location and participating adults from liability in connection with this request. I understand that the insurance benefits through the Location, if any, may have limited application, and that I am entirely responsible for the cost of all medical treatment provided to my son/daughter. I agree to indemnify and hold the Location harmless from the cost of any medical treatment and related expense and cost incurred.
  
  RELEASE OF LIABILITY: As a condition of participating in the St. Francis Xavier Religious Education program I hereby hold harmless, release and discharge The Roman Catholic Archbishop of Los Angeles, a corporation sole, Archdiocese of Los Angeles Education & Welfare Corporation and the Location, their respective agents and employees and any parent/volunteer/chaperone, from any and all liability, loss or claims for personal injuries, wrongful death or property damage that I or my son/daughter my suffer as a result of participation in Religious Education activities.
  
  PHOTO ACKNOWLEDGEMENT:
  I understand that attendees at the event will be photographed for our slide show to be shown at the end of each day and may be used to share in our church bulletin or website.
  
  I Agree Please select this field.
  
  Parent/Legal Guardian (signature) REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  COSTS
  
  Cost to attend Vacation Bible Camp REQUIRED Please fill out this field.
  
  Cost to attend Extended Care to 3:00 PM daily
  
  Total:
  
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VBS Camper Registration

REGISTER TODAY - SPACE IS LIMITED