EmailMe Form - NJMBC Vacation Bible School Form

Your Name *

Parent / Guardian's Name (if needed)

Gender *

Male

Female

Address *

Street Address City State / Province / Region Postal / Zip Code

Home Phone Number *

Cell Phone Number *

Email *

Would you like to receive text messages regarding VBS and any future VBS information/communication? By selecting "Yes" you give New Jerusalem M.B. Church permission to send you text messages regarding VBS and future VBS communication. *

Yes

No

New Jerusalem Church Member *

Yes

No

If no, where is your church home, if you have one?

Permission to use your photograph in church publications (printed pieces and church website)? *

Yes

No

Emergency Information

Emergency Contact Name *

Emergency Number *

Medical

Food Allergies *

Yes

No

If yes, please list foods allergic to here:

Other Allergies *

Yes

No

If yes, please list other allergies here:

Family Movie Day

Will you and/or your child(ren) attend the family movie day on Saturday, June 15, 2019 @ 12:00p.m? The admission will be $1 per person. The proceeds will go towards Greenville Parks and Recreation and our Mission Project.

Attending Family Movie Day? *

Yes

No

Release Disclaimer and Electronic Signature: I certify that all the information in my registration submission is accurate and true. I release New Jerusalem MB Church, Greenville Parks & Recreation and Amy Covington of all liability of above named person while participating in Vacation Bible School in said time June 10-15, 2019. Thanks!

I verify that I am 19 years of age or older. Please retype your name below for your electronic signature. Thank you! *