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 *
MM
/
DD
/
YYYY
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 *
Required
If YES, Please List
Medical Concerns *
Required
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.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of City of Wichita Falls, TX. Report Abuse