God answers prayer! Click here to submit a prayer request online or call our confidential
Prayer Line at (860-646-8731) with your need. We'll be praying and believing with you for your answer!
   
  Vacation Bible School Online Registration Form
   

Registration For 2010 Vacation Bible School
Full Gospel Interdenominational Church, Inc.

Form must be completed and submitted before June 7th.

* indicates required field

Instructions: You must complete one Online Registration for each child. After filling in this form,
you will be able to return to the Online Registration to register another child. When all your children have been registered, you will access the Payment Form to complete your registration.

If you have any questions, please call Rev. Judith Hamlin at (860) 646-9555, Ext. 16,
Monday - Friday between the hours of 9AM to 3PM.

If you are concerned about how we intend to use this information, please review our Privacy Policy.

Please Note: This form must be completed by a parent or legal guardian only.

Please enter the name of the person comleting this form below.
Include a phone number where you can be reached during
the day in case we need to verify any information.

Name of Parent or Legal Guardian completing this form :

*

Daytime Phone Number
with Area Code:

*




Child's Full Name:
*
*
Address:
*
Apt. #
City:
*
State:
*
Zip Code:
*
Phone
with Area Code:
*
Grade
In Sept.
*
Age:
*
Date of Birth:
*


Does Your Child Have a Handicap?
*
If Yes, Please Explain:



Does Child Attend Church Regularly?
*
Where:



Who Do They Attend Church With?
(May Choose More Than One)
Guardian
Other
If Other, Please Explain:
Is This Your Child's First Year Attending V.B.S.?
*
How Did You Find Out About our V.B.S.?



Could You Transport Another Child?**
*
How Many?

** I UNDERSTAND THAT THE F.G.I. CHURCH IS NOT RESPONSIBLE FOR ANY MISHAPS OR ACCIDENTS THAT MAY OCCUR.

Parents' Name:

Father:



Daytime Phone Number
with Area Code:



Mother:



Daytime Phone Number
with Area Code:



Guardian:



Daytime Phone Number
with Area Code:


Health Information


Due to your child being involved in many different areas that could include animals, insects, dyes, peanut butter, glues, etc., we ask that you provide us with the following information for their safety. In the past, some children have been allergic to some of these items, so we thank you for taking this extra time to ensure us and yourself the proper care and safety for your child.

Insurance Name:



Insurance Number:



HMO Number:





Does your child have any allergies that we need to be aware of?

*

Does your child take any medications that we need to be aware of?

*

Please Specify Where Applicable:

Medications:



Allergies:



Foods:



Plants:



Animals:



Any Other
Health Concerns:





Physician:



Phone Number
with Area Code:



Hospital:



Phone Number
with Area Code:



Emergency Contact:

*

Emergency Contact
Phone Number
with Area Code:
*
Emergency Contact Work Phone Number with Area Code:
Emergency Contact Cell Phone Number with Area Code:

Please Read the Following Statement:

I understand that the Full Gospel Interdenominational Church, Rev. Eleanor M. Kalinsky, and Youth Workers involved with Vacation Bible School, are not held responsible for any mishaps or accidents that may occur to my child during the dates of July 6 - 16, 2010.

Should any accidents or mishaps occur to my child during the July 2010 Vacation Bible School, and the church is unable to reach any of the above listed contacts, I give full permission to the Full Gospel Interdenominational Church; Rev. Eleanor M. Kalinsky, Pastor; Rev. Judith Hamlin, Youth Pastor; and Rev. Salvatore Mancini, Associate Pastor; to make any decisions concerning medical treatment and hospitalization for my child until I am able to be present.

* I certify that I have read, understand, and agree to the terms set forth in the statement above.

Media Release:

I give the Full Gospel Interdenominational Church, Inc. (F.G.I. Church) and its Mission Outreach permission to publish in print, electronic, or video format, images of my child to help promote V.B.S. and other Youth Programs of the F.G.I. Church. I release all claims against the Church and/or Mission Outreach with respect to copyright ownership and publication, including any claim for compensation related to use of the materials. I fully understand that I will receive no monetary payment for the above.

Being the Parent/Legal Guardian of the child named above, I have read and understand the terms of this media release. I also warrant that I am 18 years of age or older. I understand that the provisions of this media release are legally and perpetually binding.

*

 

Click 'Submit Application' to complete the Registration Form
and open the V.B.S. Registration Payment screen.