VBS

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Child and Youth Safety Policy

VBS Registration

Parent/Guardian 1 Name

Parent/Guardian 1 Email:

Parent/Guardian 1 Phone:

Parent/Guardian 2 Name

Parent/Guardian 2 Email:

Parent/Guardian 2 Phone:

Primary Address

City

State

Zip Code

Home Church Affiliation

One Full Copy of Sing and Play Music (select one)

Youth 1 Full Name:

Youth 1 Birthdate

Youth 1 Current Age

Youth 1 Grade Entering

Youth 1 Gender

Youth 2 Full Name

Youth 2 Birthdate

Youth 2 Current Age

Youth 2 Grade Entering

Youth 2 Gender

Youth 3 Full Name

Youth 3 Birthdate

Youth 3 Current Age

Youth 3 Grade Entering

Youth 3 Gender

Youth 4 Full Name

Youth 4 Birthdate

Youth 4 Current Age

Youth 4 Grade Entering

Youth 4 Gender

Any additional concerns or information that will help us work with your child

Parent Consent: I hereby consent to single supervision of my child(ren)

I have viewed a copy of “Child and Youth Safety Policy” at Prince of Peace Lutheran Church and am aware that Prince of Peace strives to provide dual supervision for children and youth participating in its classes and other programming.

I am also aware that circumstances may prevent dual supervision from time to time (e.g. unexpected illness of VBS leader) and that single supervision on such occasions may be permitted with written consent of a parent or guardian of a child or children involved in the activity.

Parent/Guardian Signature

VBS Registration

CONTACT US

930 W. Higgins Rd, Schaumburg, IL 60195

P: 847-885-7010

E: church@princeofpeace.net

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