Vacation Bible School

We hope you will join us for VBS! Sign up here, or download a registration form below.

Those wishing to volunteer at VBS, can CLICK HERE to register online, or print the PDF registration form at the bottom of this page.

VBS 2018 Registration Form

Please complete a separate registration form for each child you would like to register.
Preschool day runs 9AM-11AM. Kindergarten through 5th grade day runs 9AM-2PM.

* Indicates required field

Child's Name *

First

Last

How old are you? *

Parent/Guardian Name/s *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone Number *

Secondary Phone Number *

Email *

Emergency Contact Name/s and Phone Number/s *

Special Needs/Allergies/Instructions *

Dismissal Information *

Health Insurance Information and Release

While every effort is made to ensure the safety of each and every child, accidents do happen. Please supply your child's health insurance information in the event of any emergency.

Policy Holder's Name *

Insurance Company Name *

Policy/Member Number *

Primary Physician's Name *

Primary Physician's Phone Number *

By my indication below, I consent to any ex-ray, examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care under the general supervision and upon the advice of or to be rendered by a physician, surgeon, or dentist licensed under the Medical Practice Act and Dental Practice Act. As parent or legal guardian, I am responsible for the health care decisions of my child and am authorized to consent to services to be rendered, and no other consent is required by law. I hereby give permission to the physician selected by the activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist. I will assume FULL FINANCIAL RESPONSIBILITY for care given.
I warrant and represent that I am eighteen years of age or over, and am fully aware of and understand the terms and legal consequences of the signing of this form. I intend my initials below to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Initials/Date *

Submit

Kindergarten - 5th Grade Registration

K-5 Registration 2018
File Size:	381 kb
File Type:	pdf

Download File

Preschool Registration

Preschool Registration 2018
File Size:	382 kb
File Type:	pdf

Download File

Please return all paper registration forms to:

Vacation Bible School
First Lutheran Church
1000 3rd Ave SE
Cedar Rapids, IA 52403

We hope you will join us for VBS! Sign up here, or download a registration form below.

VBS 2018 Registration Form

Health Insurance Information and Release

Kindergarten - 5th Grade Registration

Preschool Registration

First Lutheran Church

1000 Third Avenue SE, Cedar Rapids, IA | 319.365.1494 | info@firstlutherancr.org | A congregation of the ELCA