City Church - VBX Registration 2024
Thank you for taking the time to fill out the following registration forms. Please fill out a separate form for each child. We look forward to having your child join us this summer. Please don't hesitate to call if you have any questions or concerns.

City Church
1680 Sparksford Dr.
Russellville, AR 72801
479-967-5882

VBX
June 24th - June 28th
9:00 - 12:30
Pre-k (must be entering kindergarten in August 2025) - 6th grade
(Grade just completed)


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Email *
Student first name *
Student last name *
Student Gender *
Student age *
Last school grade completed *
Allergies or other necessary medical information (If none, write "none") *
Please list any current medications (If none, write "none") *
Student’s T-shirt size? *
Parent(s)/Guardian(s) Name *
Parent(s)/Guardian(s) Cell Phone Number. If entering multiple numbers, please specify which number belongs to each person. *
Home Phone Number
Which number is best to reach you? *
Address *
City *
State *
ZIP Code *
Home Church
Emergency Contact (other than parent/guardian that is already listed) *
Emergency Contact Phone Number *
Emergency Contact Relationship to Child *
For safety reasons, we would like to know who is picking up your child. Each child will be given a “pick up” card and will only be released to an adult in possession of this card. Please list who will be allowed to pick up your child. If multiple people will be picking up through out the week, please list every person. *
City Church has my permission to photograph/film the minor designated above to be used for future promotional material via social media and/or church website.       *
By checking the box below, you are giving your digital signature that the above information is correct and that your child has permission to attend vacation bible school at City Church. *
Required
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