EmailMe Form - West End Baptist Church VBS 2015 Registration

West End Baptist Church VBS 2015 Registration
Vacation Bible School at West End Baptist Church
Church will be July 12-15 from 6:00-8:30 p.m. each night.

It is for grades pre-K through 5th grade.
Nursery is available for children of our volunteers.

Please fill out the following information for each child you are registering for Vacation Bible School. Thank you!

Learner's First Name:

Learner's Last Name:

Parent/Guardian Name:

Prefix

First

Last

Suffix

Parent/Guardian Name:

Prefix

First

Last

Suffix

Address:

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Home Phone:

###

####

Cell Phone:

###

####

Work Phone:

###

####

Email:

Birthday:

Last Grade Completed:

Allergies, Medical, & Special Needs:

*Emergency Contact Name (1):

*Emergency Contact Phone (1):

Emergency Contact Name (2):

Emergency Contact Phone (2):

*Authorized Pickup #1:

Authorized Pickup #2:

Authorized Pickup #3:

Authorized Pickup #4:

Are you a member of West End Baptist Church?:

Yes

I am a Guest of:

Do you attend a church?:

Yes

If so, where?:

May we have permission to photograph your child?:

Yes

May we have permission to use your child's photograph in church publications?:

Yes

Comments:

Gender:

Male

Female

Image Verification
	Please enter the text from the image: [Refresh Image] [What's This?]

EMF Free Form Builder

Report Abuse