2017 VBS: Made to Make
June 26-29 from 9:00 am to 12:00 pm and
5:30 - 7:30 pm on Thursday evening 

Name *
First Name
Last Name
Gender *
Grade Level *
If your child would like to be with a friend, please list the child's name here. Both friends must request each other.
Parent or Legal Guardian *
First Name
Last Name
Primary Phone*
Secondary Phone
Email Address
Emergency Contact Number:*
VBS Photo Statement: I understand that Harderwyk ministry activities are occasionally photographed by ministry leaders, and that my child may be photographed while participating in ministry activities. My child’s image may be used by Harderwyk Ministries for ministry related media. Please notify christinemac@harderwyk.com if you would like your child to be omitted from photos.
Release Statments *
Medical Authorization: I understand that in the event medical intervention is needed, every attempt will be made to immediately contact the person[s] listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to secure medical treatment and/or order an injection, anesthesia, or surgery for my child as deemed necessary. Liability Release: I understand all reasonable safety precautions will be taken at all times by Harderwyk Ministries and its agents during the events and activities. I agree not to hold Harderwyk Ministries, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.