Vacation Bible School

Wilderness Adventure Through the Sacraments

~~~~~~~~~~~~~~

Date: June 19th – 23rd

Ages: 4 yr. olds through rising 5th graders

Hours: 9:00 a.m. to 12 noon

~~~~~~~~~~~~~~~

We expect to fill up quickly – registration will close once we reach capacity.

**For volunteer information/questions, please email Kelly Rush at Kelly4VT@gmail.com

Registration will not be considered complete

without payment.

VBS Registration Form 2023

Please register your child for the rising grade level as of Fall 2023. No friend requests will be accepted.
Cost ** No Refunds after June 1 **
How many children are you enrolling?*
Cost is $75 for the 1st child, and $50 for each additional child.
I would also like to purchase...
- Nothing, thank you, just the registration.
- Wilderness Adventure Through the Sacraments Music CD
Total
$0.00
Student Information
Child's Full Name*
Child's Grade Level as of Fall 2023*
Child's T-Shirt Size*
Gender*
2nd Child
2nd Child's Full Name*
2nd Child's Grade Level as of Fall 2023*
2nd Child's T-Shirt Size*
Gender*
3rd Child
3rd Child's Full Name*
3rd Child's Grade Level as of Fall 2023*
3rd Child's T-Shirt Size*
Gender*
4th Child
4th Child's Full Name*
4th Child's Grade Level as of Fall 2023*
4th Child's T-Shirt Size*
Gender*
Additional Information
Name(s) of Parent(s) or Guardian(s)*
Parent Email*
Address of Parent(s) or Guardian(s)*
Street Address City State ZIP Code
Parent Home/Cell Phone
Parent Work Phone
Name of Home Church*
Emergency Contact Name*
Please name another person other than parents to be notified in an emergency.
Emergency Contact Phone*
Who may pick up your children from VBS?*
Please name the pick-up people.
Allergy Information

Allergies: Please explain pertinent allergy information in the box below.
Medical/Allergy Release
Medical/Allergy Release*
Please indicate your agreement with the following medical release:
In the event of an emergency or non-emergency situation in which medical treatment is required for my child as a result of participation with the 2023 Vacation Bible School program held at St. Theresa, Ashburn, VA, I authorize the on-site adult leaders, volunteers, and staff members to act as my agents and thereby consent to emergency medical treatment. I understand that every reasonable attempt will be made to contact me in the event of an emergency.
- I agree with the above medical release.
Name of parent digitally signing medical release*
Please type your name.
Student Drop Off/Pick Up Information*
Students cannot be dropped off prior to 8:50AM. Students must be picked up promptly at 12:00PM. PLEASE NOTE: **Only drop off exception is the first day of VBS. Drop off will be at 8:40AM**.
- I have read and understand the above drop off/pick up procedures.
Would you like to volunteer? (registration discount given for adult volunteer)*
Your Registration is Incomplete Without Payment
** No Refunds after June 1 **
Phone
This field is for validation purposes and should be left unchanged.

Vacation Bible School

Wilderness Adventure Through the Sacraments

~~~~~~~~~~~~~~

Date: June 19th – 23rd

Ages: 4 yr. olds through rising 5th graders

Hours: 9:00 a.m. to 12 noon

~~~~~~~~~~~~~~~

We expect to fill up quickly – registration will close once we reach capacity.

**For volunteer information/questions, please email Kelly Rush at Kelly4VT@gmail.com

Registration will not be considered complete

without payment.

VBS Registration Form 2023

Please register your child for the rising grade level as of Fall 2023. No friend requests will be accepted.

Cost ** No Refunds after June 1 **

Student Information

2nd Child

3rd Child

4th Child

Additional Information

Medical/Allergy Release

Your Registration is Incomplete Without Payment

** No Refunds after June 1 **

Cost No Refunds after June 1

No Refunds after June 1