College Hill VBS Registration Form
Untitled Title
Child's First Name *
Your answer
Child's Last Name *
Your answer
Grade Completed *
Your answer
Age *
Your answer
Parent/Guardian Name(s) *
Your answer
Parent/Guardian Email Address: *
Your answer
Parent/Guardian Home Address *
Your answer
Parent/Guardian Home Phone *
Your answer
Parent Guardian Alternate Phone (optional)
Your answer
Primary Emergency Contact *
First and Last Name
Your answer
Relationship to Student *
Primary Emergency Contact
Your answer
Phone Number *
Primary Emergency Contact
Your answer
Alternate Phone Number (optional)
Primary Emergency Contact
Your answer
Secondary Emergency Contact (optional)
First and Last Name
Your answer
Relationship to Student
Secondary Emergency Contact
Your answer
Phone Number
Secondary Emergency Contact
Your answer
Alternate Phone Number (optional
Secondary Emergency Contact
Your answer
Does your child have any food allergies? *
Required
If so, please explain:
Your answer
Medical Concerns? *
Required
If so, please explain:
Your answer
Name of Your Child's Primary Health Insurance Company *
If you do not have health insurance, please write "none".
Your answer
Policy # *
If you do not have health insurance, please write "N/A".
Your answer
Policy Holder's Name *
If you do not have health insurance, please write "N/A".
Your answer
Family Doctor *
If your child doesn't have a family doctor please write "none".
Your answer
Family Doctor's Phone Number *
If you do not have a family doctor please write "N/A".
Your answer
What was the year of your child's last tetanus shot?
If your child has never received this vaccination, or if you are unsure of the year, please leave this entry blank.
Your answer
Does your child have any siblings attending VBS? *
Required
If so, please list their names and ages:
Your answer
Do you or your child have a church home? (optional)
Church Name? (optional)
Your answer
Please list any person who has your permission to pick up your child from VBS in addition to you: *
If there is no one, please write "none".
Your answer
Does your child have permission to appear in pictures taken of VBS activities? *
Required
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