EmailMe Form - VBS Registration

Child's Name *

First Last

Email *

Confirm

Grade Completed *

Birthday *

MM / DD / YYYY

Current Age *

Parents' names *

First Last

Parents' names

First Last

Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Contact Phone: *

### - ### - ####

Emergency Contact Person *

First Last

Relationship to student *

Emergency Phone *

### - ### - ####

Food allergies: *

Yes

No

Please list Food allergies:

Medical concerns: *

Yes

No

Please explain medical concerns:

Family Doctor *

First Last

Doctor's Phone *

### - ### - ####

Siblings attending VBS (names and ages):

Church affiliation:

Church membership at:

People who may pick up the child:

Transportation needed? *

Yes

No

Attendance

Parent's signature (Type full name) *

VBS leaders have permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with VBS program.