2024 VBS Child Registration Form

June 3-6, 2024 | Please fill out this form and click submit.

Child # 1 Information

Name

*

Date of Birth

*

Gender

Please select all that apply.

Male Female

School Grade in Sept

*

Please select one option.

Prek3 (Potty Trained) Prek4 Kindergarten 1st 2nd 3rd 4th 5th

Child #2 Information

Name

Date of Birth

Gender

Please select one option.

Male Female

School Grade in Sept

Please select one option.

Prek 3 (Potty Trained) Prek 4 Kindergarten 1st 2nd 3rd 4th 5th

Child #3 Information

Name

Date of Birth

Gender

Please select one option.

Male Female

School Grade in Sept

Please select one option.

PreK 3 (Potty Trained) Prek4 Kindergarten 1st 2nd 3rd 4th 5th

Child #4 Information

Name

Date of Birth

Gender

Please select one option.

Male Female

School Grade in Sept

Please select one option.

Prek3 (Potty Trained) Prek4 Kindergarten 1st 2nd 3rd 4th 5th

Parent Information

Name

*

Address

*

Phone

*

Email

*

This address will receive a confirmation email

Church You Attend:

Emergency Contact

Name

*

Phone

*

Relationship to Child(ren)

*

In Case of Emergency

Physicians Name

*

Physicians Phone

*

Preferred Hospital:

*

Hospital Address

*

Health & Food Concerns

Food Allergies

*

Please select all that apply.

Yes No

List of Allergies (please specify which child(ren)).

Medical Treatment/Special Needs:

Pick-up information

Name

*

Phone

*

Relationship to Child

*

Please select one option.

Mother Father Guardian Grandparent Other

Releases / Permissions

Permission to photograph my child(ren) and use it for the purpose of promotion

*

Please select all that apply.

Yes No

Please review our release information by clicking this Link

Authorization to Participate

*

Please select all that apply.

Yes No

Authorization for Treatment

*

Please select all that apply.

Yes No

Comments

Description

June 3-6, 2024

Please fill out this form and click submit.

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