August 2-4

Deadline to register is July 24th

Pentecostals of Peoria

3510 W. Malone St. Peoria, IL 61605

(309) 637-8359

Times: August 2: 7 PM - 8:30 PM

August 3: 6:30 PM - 8:30 PM

August 4: 6:30 - 8:30 PM 



Ages: 5-11

Attire: Casual

Snacks will be provided nightly.

Please try to be on time to pick up your children.

Personal Information *
Personal Information
Address *
Parent/Guardian Information
Parent/Guardian Information
List all known medical conditions/allergies and over-the-counter or prescription medications taken regularly.
Is there any other information you feel we should know about your child(ren)? If yes, please explain below.
In the event of an emergency or non-emergency situation requiring medical treatment, I, the above listed parent/guardian, hereby grant permission for any and all medical and/or dental attention to be administered to my child in the event of any accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recomendation of qualified personnel. I release and waive any claim I may have against the Pentecostal of Peoria, or the individual members, agents, employees and representatives of either entity, as well as trip supervisors and drivers for any losses, damages, or injuries arising out of, during, or in connection with the participation of the student named herein the 2017 Vacation Bible School or the rendering emergency medical procedures or treatment (if any emergencies take place.) By electronically signing this statement, I affirm the information of this form is correct, agree to all consents and waivers, and hereby grant permission for the student named herein to participate in the 2017 POP Vacation Bible School.