Vacation Bible School

Vacation Bible School Registration Form 2023

Registration Fee:
$15 per child
$25 2 or more children

Financial assistance is available.

Please make all checks out to:
All Saints Parish and mail to:
All Saints Parish, Faith Formation,
128 N. McKean St. , Butler, PA 16001

Child's name: REQUIRED Please fill out this field. Please enter valid data.

Child's gender: REQUIRED Please fill out this field.

Child's age 3 4 5 6 7 8 9 10 11

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Last school grade completed: Please enter valid data.

Name of parent: REQUIRED Please fill out this field. Please enter valid data.

Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Parent's Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Caregiver's Phone Number Please enter a phone number.

Parent's Email REQUIRED Please fill out this field. Please enter an email address.

Are you are parishioner? REQUIRED Yes No Please fill out this field.

In case of emergency, contact (name): REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact's Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Relationship to student REQUIRED Please fill out this field.

I/We the undersigned parents/guardians of the following registrant, a minor, do hereby authorize treatment of my/our child by a licensed medical physician in case of any accident or illness that may arise, or any hospitalization necessary. REQUIRED Please fill out this field. Please enter valid data.

This constent will remain in effect from June 26-30, 2023 for those attending VBS at All Saints Parish - St. Conrad campus.

Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

Of the following statements pertaining to medical matters, sign only those in accordance with your wishes.

MEDICATIONS: My child is taking medication and will bring all such medication necessary in their original bottles. Please list the names of medications that need to be taken during the time of VBS, dosage, and frequency of dosage:

Signature Please enter valid data.

Date Please enter a date.

I hereby grant permission for non-prescription medication (such as Tylenol, throat lozenges, cough syrup, etc.) to be given to my child, if deemed advisable. Sign below: Please enter valid data.

Date Please enter a date.

No medication of any type whether prescription or non-prescription may be administered to my child unless the situation is life-threatening and emergency treatment is required. Sign below: Please enter valid data.

Date Please enter a date.

Allergies, medical conditions, or special needs:

We occasionally photograph/video events for our bulletin, website, social media sites and other communication means. Leave blank if you do NOT want your child to be photographed/videoed in Faith Formation events

I Agree Please select this field.

All Saints Parish

St. Andrew + St. Conrad + St. Michael + St. Paul + St. Peter

Vacation Bible School

2023 Vacation Bible School

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