2019 VBS Registration

one application per child

Child's Name

MaleFemale

Parent/Guardian Name

Address

Numbers
Home
Work
Cell

Email

Date of Birth

Grade
Pre-KK1st2nd3rd4th5th

Medical Information
Medical or other information we need to know. Please include any food allergies

Emergency Contacts
Name

Phone number

Name

Phone number

Dismissal Information
Who may pick up your child at the end of each VBS day?
May we have permission to photograph your child? YesNo
May we have permission to use your child's photograph in church publications for the purpose of promotion? YesNo

Parent's Signature