Hero Central Vacation Bible School Registration Form Please complete and submit the following form to register for Capitol Hill Assembly’s Hero Central Vacation Bible School! If you are a human and are seeing this field, please leave it blank. Child's First Name Child's Last Name Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampsireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone Age Date of Birth Grade COMPLETED as of June 2017 Email Name of Parent/Guardian Please list those who may have permission to pick up my child from Vacation Bible School: Please list any food allergies: Please list any medical concerns or special instructions: By checking this box, I hereby authorize Capitol Hill Assembly to administer emergency medical care should it become necessary, understanding that I will be contacted immediately in such an event. In the event that someone cannot be reached, I hereby authorize a church representative to secure proper treatment necessary for my child named above. I accept responsibility for payment of expenses incurred as a result of medical treatment. By checking this box, I hereby release Capitol Hill Assembly and all its participants from any liability or damage to or loss of personal property, sickness or injury from whatever source which might occur while attending this event. I understand that by attending this event I give Capitol Hill Assembly permission to use my child's image on it's church Facebook page, church website, video, and other media, knowing that all media is used for promotional purposes only.