St. Thomas Vacation Bible School 2017 July 31, 2017 – August 4, 2017 9 a.m. - 12 p.m. St. Thomas Episcopal Church 98 Sky Manor Road Pittstown, NJ 08867 (908) 996-4091 * Deadline for signing up is July 7. St. Thomas Vacation Bible School Signup Form Participant(s) Full Name (required) Grade Participant Full Name (required) Grade Participant Full Name (required) Grade Your Email (required) Day Phone # (required) Phone: Cell: Address (required) City (required) State (required) ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code (required) Emergency Contact (required) Phone: IMPORTANT – PLEASE READ THE FOLLOWING STATEMENT: **I hereby waive and release all rights and claims for damages against St. Thomas Episcopal church and their employees and agents for all injuries, which way be sustained by the herein named minor or myself while participating in the VBS program. I understand the content of the program and the risks of personal injury therein. I also give my permission for employees of the church and the Hunterdon Medical Center to admit my child for EMERGENCY medical treatment that would become necessary as a result of a medical emergency during this program. Any information provided will be treated with confidentiality. I, , parent or official guardian of , hereby grant permission to St. Thomas Episcopal Church representatives, to take and use: photographs and/or digital images of my child for use in news releases and/or promotional materials. You may withhold this data, but you might not receive appropriate care without it. DOES PARTICIPANT TAKE ANY MEDICATION (S): YesNo List Medications: DOES PARTICIPANT HAVE ANY MEDICAL CONDITIONS OF WHICH THE STAFF SHOULD BE AWARE? YesNo Please check any conditions that apply: Attention DeficitHyperactivity DisorderEpilepsyDiabetesAsthmaDietary RestrictionsOppositional Defiant Disorder Other DOES THE PARTICIPANT REQUIRE ANY ACCOMMODATION FOR DISABILITY? YesNo If so, please explain DOES THE PARTICIPANT HAVE ANY ALLERGIES? YesNo If so, please explain: DOES THE PARTICIPANT CARRY AN EPIPEN? YesNo If so, please explain: Please Sign Below (required) **Click if you agree to the above waiver.