EmailMe Form - VBS 2010 Registration

VBS 2010 Registration
New Hope Baptist Church
830 Choate Rd; Salisbury, NC 28146
(704) 633-2107

July 11th-15th; 6:00pm nightly

Child's Name *

Prefix

First *

Last *

Suffix

Father's Name *

Prefix

First *

Last *

Suffix

Mother's Name *

Prefix

First *

Last *

Suffix

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Birthdate *

YYYY

Phone Number *

###

####

Email *

Transportation *

I NEED a ride to VBS

I have a ride to VBS

I don't know

Allergies/Special Medical Attention Needs: *

In Case of Emergency, Contact: *

Pickup Authorization:

The following people are allowed to pick up my child from VBS 2010. If someone else besides myself or the following come to pick up my child, I understand that the staff WILL NOT RELEASE my child to them until I have been contacted and approve of the pickup.

Name

Prefix

First

Last

Suffix

Name

Prefix

First

Last

Suffix

Name

Prefix

First

Last

Suffix

Permission Authorization

By placing my name in the boxes below, I, as the parent or legal guardian or the above child, am giving my permission for the above child to attend VBS 2010. I also give my permission for the staff to seek medical attention as they deem necessary for the above child. I will not hold New Hope Baptist Church, the VBS staff, or any other individual responsible for any injuries that the above child may sustain or financial burdens that may be incurred because of injury during VBS 2010. I give my permission for my child to ride on transportation provided by New Hope Baptist Church, if nessesary.

Parent/Legal Guardian Name *

Prefix

First *

Last *

Suffix

Date

YYYY

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