VBS Registration - Emmanuel Baptist Church
July 19-23, 2021 from 6:00pm-8:30pm (Ages 3 - completed 5th grade)

Please fill out one form per child attending
Email *
Child's Name (Last, First, MI) *
Name Child Likes To Be Called, If Different Than Above
Grade Completed
Child's Birthday *
Age On July 19, 2021 *
Parent's Name(s) *
Home Address *
Contact Phone Number *
Alternate Phone Number
Emergency Contact Person *
Relationship To Child: *
Emergency Contact Person Phone Number *
Emergency Contact Person Alternate Phone Number
Child Food Allergies *
If YES, Please List
Medical Concerns *
If YES, Please List
Child's Doctor
Doctor's Phone
Siblings Attending VBS (Names & Ages)
Church Affiliation
Church Membership At
Person(s) Name(s)/Phone Number(s) Who May Pick Up The Child *
Church Staff/VBS Leaders Have Permission To Photograph The Child Designated Above For Any Lawful Purpose Associated With This VBS Program *
Anything Else We Need To Know
A copy of your responses will be emailed to the address you provided.
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