2096 Independent Road
Breinigsville, PA 18031
610-285-2235
Lighthouse Home
Welcome to the Lighthouse
About Us
Contact Us
What We Believe
Lighthouse History
Events & Calendar
Directions
Sermons & Music
Vacation Bible School
Registration Page
Please register one child at a time. All items marked with an asterisk (*) must be completed.
Is this child also registered for Push The Rock?
*
Yes
No
*
Indicates required field
Child's Name
*
First
Last
Birthdate
*
Person Filling Out Form
*
First
Last
Relationship to child?
*
Email
*
Address of child
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
*
If you do not have a home phone, please enter the best number where you can be reached.
Cell Phone Number
*
Emergency Contact
*
Some one who is available during the days and times of VBC.
Emergency Contact Phone Number
*
Will your child be eating lunch with us? Lunch will be from 12:00 to 12:30 and is available to any child attending either program.
*
Yes
No
Does your child have any food allergies or medically require a special diet?
*
Yes
No
If you checked "Yes", please list details below.
*
Does your child have other allergies including medications?
*
Yes
No
If you checked "Yes", please list details below.
*
Does your child have any physical condition or illness which would prevent him/her from participating in normal, rigorous activity?
*
Yes
NO
If you checked "Yes", please list details below.
*
Medical Treatment Authorization: I understand that I, or the emergency contact listed, will be notified in the case of a medical emergency involving my child(ren). However, in the event that I, or the emergency contact, cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event our child(ren) is injured or becomes ill. I authorize a church representative to make emergency medical care decisions on behalf of our child(ren), if required by law or a health care provider. I understand that the Lighthouse Baptist Church of the Lehigh Valley or any of their agents, employees, or volunteers, will not be responsible for medical expenses incurred on the basis of this authorization.
*
Yes, I understand.
I hereby give The Lighthouse Baptist Church of the Lehigh Valley and their legal representatives the irrevocable right to use my child’s (children's) first name (or any fictional name), picture, portrait, or photograph in all forms and media and in all manners, including but not limited to, composite or distorted representations, for advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished product, including written copy, that may be created in connection therewith.
*
I give permission.
I DO NOT give permission.
By clicking the "Submit" button below, I verify that I am the parent/guardian of the minor named above and have the legal authority to execute the above release. I have read this release and fully understand its contents. I approve the foregoing and waive any rights in the premises.
*
Yes, I verify.
Submit
For a Printable VBS Registration Form
Click
Here
Push The Rock Registration
