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Youth Registration

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Child's Information

Name *

First

Last

Date of Birth *

Gender *

Female
Male

T-Shirt Size *

Please Select *

Food Allergies
Medical Concerns
None

Please list all food allergies.

Please list all medical concerns.

Register another Child

Second Child's Information

Name *

First

Last

Date of Birth *

Gender *

Female
Male

T-Shirt Size *

Please Select *

Food Allergies
Medical Concerns
None

Food Allergies

Medical Concerns

Register another child

Third Child's Information

Name *

First

Last

Date of Birth *

Gender *

Female
Male

T-Shirt Size *

Please Select *

Food Allergies
Medical Concerns
None

Food Allergies

Medical Concerns

Register another child

Fourth Child's Information

Name *

First

Last

Date of Birth *

Gender *

Female
Male

T-Shirt Size *

Please Select *

Food Allergies
Medical Concerns
None

List all food allergies

List all medical concerns

Consent

Consent *

I, the undersigned, parent, or legal guardian of the minor child or children list on this registration form do hereby consent to the participation of my minor(s) in West Central Church of Christ 2024 vacation bible school.

Medical Treatment Authorization

Medical Treatment Authorization *

I understand that I will be notified in the case of a medical emergency. However, if I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services if my minor child is injured or becomes ill. I authorize the vacation bible school staff and volunteers at West Central Church of Christ to make emergency medical care decisions on behalf of my minor child, if required by law or a health care provider. I authorize these persons to act in my place to consent to all necessary and appropriate x-ray(s), examination(s), anesthetic, medical or surgical diagnosis or treatment(s), and hospital care. I understand that the vacation bible school staff, volunteers, and West Central Church of Christ will not be responsible for any medical expenses incurred solely based on this authorization.

Publicity Release

Publicity Release *

I, the undersigned parent, or legal guardian of the minor(s) listed on this registration form, authorize and grant permission to West Central Church of Christ and its authorized agent, to use the minor(s) child’s photographic image for any electronic or non-electronic form or media. I agree that the image may be reproduced, edited, or used in whole or part for any and all media, including but not limited to print, audio-visual, multimedia, promotional material and social media. I understand and agree that I or the minor child have no rights to any benefits derived from any such image.

Parent/Guardian Information

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

Name *

First

Last

Phone *

Custom Captcha *

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Join Us For On-line Worship Service

Regular Schedule

Sunday
Bible Classes for all ages: 9:30 AM
Morning Worship Service: 10:30 AM

Tuesday
Community Lunch - 11:30 am

Wednesday
Morning Bible Class: 11:00 AM
Evening Bible Class: 7:00 PM

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Regular Schedule

Sunday
Bible Classes for all ages: 9:30 AM
Morning Worship Service: 10:30 AM
Evening Worship Service: 5:30 PM

Tuesday
Community Lunch - 11:30 am

Wednesday
Morning Bible Class: 11:00 AM
Evening Bible Class: 7:00 PM

Keep in touch

4662 Delmar Blvd.
St. Louis, MO 63108
PH: 314 367-0060
FAX: 314 367-2506

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