VBS Registration Form 2022

VBS Student Registration Form

STUDENT INFORMATION

* Indicates required field

Child's First and Last Name *

Child's Age *

Child's Birthdate *

GRADE AS OF FALL 2022 *

Child's T-Shirt Size *

Parent/Guardian First and Last Name(s) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone *

Secondary Phone *

Email *

Preferred Method of Contact *

Does Your Family Attend Church? *

YES NO

If yes, name of church *

EMERGENCY INFORMATION

Emergency Contact 1 Name *

Contact 1 Phone Number *

Emergency Contact 2 Name *

Contact 2 Phone Number *

Preferred Physician *

Physician Phone Number *

Allergies or Special Needs *

DISMISSAL

Who else may pick up your child at the end of the day? *

Only Parent/Guardian Listed Above See Below

Name *

Relationship *

Kick-Off Cookout
JULY 16
10:00am - 12:00pm