Student name(s) and age(s):*

We plan to attend:*

Parents' Names*

Home Address:*

City, State, Zip*

Home Phone:*

Cell Phone:

email address:*

Emergency Contact:*

Phone Number:*

Person(s) picking up child(ren):*

If your child has allergies or medical conditions, please explain here:

Church member at:

Number planning to attend free dinner served 4:30-5:30 PM:*

I, the undersigned, do hereby grant or deny permission to St Paul's Evangelical Lutheran Church and School to use the image of my child(ren) listed above, as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images in the promotion of the Vacation Bible School.*