Participating Child S First Last Name(S)

St. Mary Catholic Church, VINTON

2016V.B.S. Registration Form due no later than July 18th!

Early sign up is appreciated! Call 319-472-3368 or email by July 11th!

V.B.S. Dates: July 18 - 21, 20161:00-5 pm

**V.B.S. is for children Kindergarten through 5th Grade in the fall of 2016.

Participating child’s first last name(s):

1. ______Age ___ Grade for 2016/17___

2. ______Age ___ Grade for 2016/17 ___

3. ______Age ___ Grade for 2016/17___

4. ______Age ___ Grade for 2016/17___

Parent/Guardian names: ______

Address: ______

Home telephone: ______Cell phone: ______

Home email address: ______

In case of emergency (when the parent/guardian cannot be reached), please contact:

Name: ______

Telephone: ______

Relationship to child: ______

Please list name of child and any allergies/medical needs the VBS staff should be aware of: ______

______

Person responsible for picking up child/children at the end of each VBS day:

Name: ______Telephone number: ______

Signature of parent/guardian: ______

**PLEASE PRINT and COMPLETE THE REGISTRATION FORM (front & back) andbring form with you the first day of V.B.S. along with a $10 donation per child.

OR You may mail form and donation to: Diane Walston, Heart of Mary Cluster, 2200 2nd Avenue, Vinton, IA 52349

Please make checks payable to: Heart of Mary Cluster

Questions? Call Diane Walston at 319-472-3368 or email:

VOLUNTEERS NEEDED to help V.B.S. run smoothly! Adults and youth from 6th grade on up are needed to lead activities and assist participants! Call Diane Walston at 319-472-3368 or email: to volunteer!

Registration form continued next page…

Minor Hold Harmless/Indemnity Agreement

(One form per family)

PARISH: St. Mary Catholic Church, Vinton

MINOR ACTIVITY PARTICIPANT:______

DATES OF ACTIVITY OR USAGE: July 18-21, 2016

TYPE OF ACTIVITY OR USAGE: VacationBibleSchool

The above named ACTIVITY PARTICIPANT or FACILITY USER agrees to defend,

protect, indemnify and hold harmless the above named PARISH against and from all

claims arising from the negligence or fault of the above named ACTIVITY PARTICIPANT or FACILITY USER or any of their agents, family members, officers,

volunteers, helpers, partners, organizational members or associates which arise out of the

above named ACTIVITY or USAGE at the above named PARISH.

Additionally, as legal guardian for the above named ACTIVITY PARTICIPANT or

FACILITY USER, I agree to protect, defend, hold harmless and fully indemnify the

above named PARISH for any claim or cause of action whatsoever arising out of the

above mentioned ACTIVITY or USAGE which takes place during the above identified

DATE(S) OF ACTIVITY or USAGE that is brought against the PARISH by the above

named ACTIVITY PARTICIPANT or FACILITY USER or their family members

whether such claim arises from the alleged negligence of the PARISH, its employees or

agents or ACTIVITY PARTICIPANT or FACILITY USER’S negligence.

As parent and/or legal guardian, I remain legally responsible for any personal actions

taken by the above named minor (“participant”).

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns,

to hold harmless and defend _St. Mary Catholic Church, Vinton_, its officers, directors and agents, and the Archdiocese of Dubuque.

If any portion of this agreement is held invalid, it is agreed that the balance thereof, shall

continue in full force and effect.

PARENT SIGNATURE:______

PARENT NAME (Please print):______

DATE:______

Confidential Form