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2018 Rolling River Rampage VBS Registration Form

Student's Name *
Student's Name
Parent/Guardian Name *
Parent/Guardian Name
Address *
Address
Phone *
Phone
Student Date of Birth *
Student Date of Birth
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 Phone *
Emergency Contact #1 Phone
Emergency Contact #2
Emergency Contact #2
Emergency Contact #2 Phone
Emergency Contact #2 Phone
Media Consent Form *
I consent to the use of my child's image or voice in photographs, audio, and/or video recordings taken during the course of the Wickline United Methodist Kids' Programs. These images will be used for the purpose of publicising the programs, including but not limited to the use in the church newsletter, worship services of the church, placement on the chruchs internet website, and placement on church bulletin boards. If you DO NOT want your child's image or voice used, please complete the above form and mark "I do not agree" below.
Date *
Date
Parent/Legal Guardian's Name (Signature) *
Parent/Legal Guardian's Name (Signature)