EmailMe Form - NLBC VBS 2013 Registration

Parent/Guardian Name *

Prefix First Last Suffix

Phone *

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

Email *

Address *

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

In the event of an emergency, New Life Baptist Church has my permission to obtain Emergency Services" *

Yes

No

Emergency / (Other Persons Authorized to pick up child
) Contact(s) information

Emergency Contact #1 - Name *

Prefix First Last Suffix

Relationship *

Phone *

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

Emergency Contact #2 - Name

Prefix First Last Suffix

Relationship

Phone

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

Children(s) Information

1. Child's Name *

First Last

1. Child's Age *

Last Grade Child completed *

Allergies/Special Needs/Current Medications / Instructions (Please include any food or medical allergies) *

2. Child's Name

First Last

2. Child's Age

Last Grade Child completed

Allergies/Special Needs/Current Medications / Instructions (Please include any food or medical allergies)

3. Child's Name

First Last

3. Child's Age

Last Grade Child completed

Allergies/Special Needs/Current Medications / Instructions (Please include any food or medical allergies)

Name of the church you attend *

If you are visiting, who are you a guest of?

May we have permission to photograph you and/or your child? *

Yes

No

Would you like to be notified about VBS next year?

Yes

No

I am aware by clicking the "register" button - that serves as my electronic signature and completes the registration process *

Yes

Name of person submitting registration *

First Last

Emergency / (Other Persons Authorized to pick up child ) Contact(s) information

Children(s) Information

Emergency / (Other Persons Authorized to pick up child
) Contact(s) information