LifeBridge VBS 2017
Registration Form
We are excited you are choosing to join us at our VBS "Gadgets & Gizmos" this year!  Our event is July 17 - 21 from 9:00 am - NOON.  We have a great program prepared for your child and we trust they will enjoy each day.

To register your child for VBS 2017, please fill out this online registration form completely. You will note that all required sections are marked with an *asterisk. If no answer is available, please enter NONE in the box.

The age range for VBS 2017 is children 4 years old to 5th grade (in September). Children 3 1/2 years old who are potty trained are accepted if their birthdates falls after January 1, 2014.

Registration fees are $50 each for the first two children and $25 per child after that. (1 child=$50, 2 children=$100, 3 children=$125, 4 children=$150, 5 children=$175)

Once you receive your registration confirmation email, follow the instructions to either pay online or print out a form to mail in with your payment or you can drop it by the LifeBridge Office anytime between 9 a.m. - 4 p.m., Monday through Friday.

If you have any questions about our VBS, please email Pilar Gross at bridgekidsvbsreg@gmail.com or call her at 858.776.9388.
Get Started
 
What's your first name? *

 
What's your last name? *

 
What is your address?

 
If we need to contact you, what is the best number to reach you at? *

 
Let's register your first child.

 
What is your child's first name? *

 
What is your child's last name? *

 
What is {{answer_51129897}} date of birth? *

 
What is your child's gender?


 
Grade in September? *


 
What size t-shirt would {{answer_51129897}} like? *


 
Any detary restrictions, allergies, or learning disabilities we need to be aware of?

(Please be specific to give your child the best experience possible!)
 
Please list any significant health problems of child.

 
List All Current Medications That Your Child is Taking

 
Does your child have any physical activity restrictions?

     
 
Please list restrictions below

 
Would you like to register another child? *

     
 
Let's register your second child.

 
What is your child's first name? *

 
What is your child's last name? *

 
What is {{answer_51251117}} date of birth? *

 
What is your child's gender?


 
Grade in September? *


 
What size t-shirt would {{answer_51251117}} like? *


 
Any detary restrictions, allergies, or learning disabilities we need to be aware of?

(Please be specific to give your child the best experience possible!)
 
Please list any significant health problems of child.

 
List All Current Medications That Your Child is Taking

 
Does your child have any physical activity restrictions?

     
 
Please list restrictions below

 
Would you like to register another child? *

     
 
Let's register your third child.

 
What is your child's first name? *

 
What is your child's last name? *

 
What is {{answer_51251163}} date of birth? *

 
What is your child's gender?


 
Grade in September? *


 
What size t-shirt would {{answer_51251163}} like? *


 
Any detary restrictions, allergies, or learning disabilities we need to be aware of?

(Please be specific to give your child the best experience possible!)
 
Please list any significant health problems of child.

 
List All Current Medications That Your Child is Taking

 
Does your child have any physical activity restrictions?

     
 
Please list restrictions below

 
Would you like to register another child? *

     
 
Let's register your fourth child.

 
What is your child's first name? *

 
What is your child's last name? *

 
What is {{answer_51251181}} date of birth? *

 
What is your child's gender?


 
Grade in September? *


 
What size t-shirt would {{answer_51251181}} like? *


 
Any detary restrictions, allergies, or learning disabilities we need to be aware of?

(Please be specific to give your child the best experience possible!)
 
Please list any significant health problems of child.

 
List All Current Medications That Your Child is Taking

 
Does your child have any physical activity restrictions?

     
 
Please list restrictions below

 
Would you like to register another child? *

     
 
Let's register your fifth child.

 
What is your child's first name? *

 
What is your child's last name? *

 
What is {{answer_51251294}}date of birth? *

 
What is your child's gender?


 
Grade in September? *


 
What size t-shirt would {{answer_51251294}} like? *


 
Any detary restrictions, allergies, or learning disabilities we need to be aware of?

(Please be specific to give your child the best experience possible!)
 
Please list any significant health problems of child.

 
List All Current Medications That Your Child is Taking

 
Does your child have any physical activity restrictions? *

     
 
Please list restrictions below

 
Name of friend(s) you would like your child to be in a group with:

 
How did you hear about our VBS?


 
Does your family regularly attend a local church?

     
 
What is the name of your home church?

 
Release and Insurance Information

 
Photo Release *

I authorize LifeBridge Church, at its sole discretion, to use and publish for any lawful purpose and without compensation, photographs, video, audio and/or depictions of the above named child/children attending the above event.  These images could be in (but not limited to) printed publications, on the LifeBridge Church website or in it's social media accounts.

By typing in your full name, you authorize the Photo Release
 
Health Insurance Carrier *

 
Policy Number *

 
Name of Principal Insured *

 
Relationship To Student/Child *

 
Primary Doctor's Name *

 
Doctor's Office Phone Number *

 
Are Tetanus shots up to date for your child(ren)? *

     
 
1. On-site Medical Treatment Consent *

Permission is hereby granted for the nurses and/or medical representatives from LifeBridge Church to administer approved emergency first aid care as necessary. (Band-Aids, Neosporin, ice pack, etc.)  By typing in your full name, you authorize the ON-SITE MEDICAL TREATMENT. If NO - type NO.
     
 
2. Off-Site Medical Treatment Consent *

I hereby authorize medical treatment, administration of anesthesia, and surgical treatment(s) for my child/children, in the event a medical situation occurs and the hospital or physician(s) are unable to contact me. This authorization extends to any hospital and to any physician and nursing personnel within the hospital, as well as to any physician where treatment is rendered in the physician's office. I release from medical responsibility and liability the hospital, medical authorities, and the physicians acting on the authority of this medical treatment consent form to give any care which is deemed necessary for my child/children. (By typing in your full name, you authorize the OFF-SITE MEDICAL TREATMENT.  If NO - type NO.)
     
 
Is there anything else you would like us to be aware of?

 
We are just about done with registration. Next step is to pay the registration fees. Total for your kid(s) is: {{var_price}}

If you prefer to pay by check, you can choose continue to skip payment.
 
Please enter your Credit or Debit Card number:

 
The CVC number:

(3 or 4 digit security number on the back of your card)
 
The name on your card:

 
Your card's expiry month:


 
Your card's expiry year:


Registration is complete. You will receive a confirmation email in a moment.

See you at VBS!
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