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VBS REGISTRATION
Email address *
Parents Name (s) *
Your answer
Email *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone *
Your answer
#1 In an emergency, if we cannot reach you, who can we call? *
Your answer
Phone *
Your answer
Relationship to Child? *
Your answer
#1 Are there any persons authorized to pick up your child(ren) other than those listed above? Name
Your answer
Phone
Your answer
Relationship to child
Your answer
#2 Are there any persons authorized to pick up your child(ren) other than those listed above? Name
Your answer
Phone
Your answer
Relationship to Child
Your answer
#1 Child's name *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Grade in School (Starting in Fall) *
Your answer
Allergy/Medical Info *
Your answer
#2 Child's Name
Your answer
Birth Date
MM
/
DD
/
YYYY
Grade in School (Starting in Fall)
Your answer
Allergy/Medical Info
Your answer
#3 Child's Name
Your answer
Birth Date
MM
/
DD
/
YYYY
Grade in School (Grade in Fall)
Your answer
Allergy/Medical Info
Your answer
#4 Child's Name
Your answer
Birth Date
MM
/
DD
/
YYYY
Grade In School (Grade in Fall)
Your answer
Allergy/Medical Info
Your answer
I am aware that individual and group photos/videos are taken throughout VBS and that my child's picture may appear in Rushsylvania Church of Christ publicity or advertising and by my electronic signature I hereby voluntarily grant my permission for this purpose. And that I am a legal parent or guardian of the children named on this online registration. *
Type Full Name
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