2025 VBS REGISTRATION

AGES: 3-years-old (potty-trained) thru completed 4th grade
WHERE: Alleluia Lutheran Church, 10401 30th Street NE, St. Michael

Half Day (8-Noon) $80/Child: Drop off from 8-9am; VBS programming runs from 9-noon; Snacks and drink available; Pick up is at noon. $80/child and includes a cape if registration is paid and received by July 20th.

*Registration NOT complete without payment*

Registration INCLUDES Cape if received by June 20th

ALL ARE WELCOME!
Questions? Contact Jen Teachout @ cyf@alleluialutheranchurch.org

Office Phone: (763) 497-5816

CHILD 1

Child's First, Middle & Last Name:

Date of Birth (00/00/00):

Age:

Completed Grade as of June 2025:

CHILD 2

Child's First, Middle & Last Name:

Date of Birth (00/00/00):

Age:

Completed Grade as of June 2025:

CHILD 3

Child's First, Middle & Last Name:

Date of Birth (00/00/00):

Age:

Completed Grade as of June 2025:

PARENT / GUARDIAN CONTACT INFORMATION

Name:

Address:

Phone:

Email:

This address will receive a confirmation email

Date:

If not connected to Alleluia, would you like to be?

I am interested in membership No thank you, just here for VBS We are already connected!

Additional Comments:

VOLUNTEER OPPORTUNITIES

We need your help to make this a success. Great opportunity for confirmation students!

YES! I am interested in helping with VBS! Please contact me with volunteer opportunities. YES!

HEALTH INFORMATION

Insurance Carrier:

Group Number:

Carrier Address :

Carrier Phone Number:

Full Name of Insured:

ID#:

Primary Physician:

Physician's Phone Number:

Is your child(ren) immunizations current?

Yes No

Date of last tetanus booster for each child:

EMERGENCY CONTACT

If unable to reach parent in an emergency, contact:

Phone:

Relationship to Child:

SPECIAL INFORMATION

Does your child take either prescription or non-prescription medication on a regular basis?

Yes No

If yes, please state name of child, medication and reason:

Health or behavior concerns that we should be aware of: asthma, diabetes, epilepsy, ADD, ADHD, etc.:

Allergies:

Other:

PERMISSION SECTION (PLEASE INITIAL)

Release from Liability: Guardians hereby authorize my son/daughter to participate in said activity. Guardians hereby release, forever discharge and agree to hold harmless, Alleluia Lutheran Church, from the described event, and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expense, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the described event. The undersigned further hereby agrees to hold harmless and indemnify Alleluia Lutheran Church, its director, employees and agents for liability sustained by said act of said participant, including any expenses incurred.

AGREE (please initial):

Medical Release: The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify Alleluia Lutheran Church, its director, employees and agents from any acts of misconduct, and/or failure to act on the part of those chosen to administer medical aid on behalf of participant.

AGREE (please initial):

Pictures: I agree to allow Alleluia! to take pictures of my child(ren) during camps. I understand that these photos may be used for programming and publicity purposes only.

AGREE (please initial):

PAYMENT (Half Day: $80/Child

Total Payment for Child(ren) Registered

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

August 4-7, 2025 at 9AM

2025 VBS Registration

2025 VBS REGISTRATION

Description

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