VBS Registration 2019
Dates / Location: June 5-8,2018 @ Blessed Sacrament School 1105 E. Highland Dr
Pre-K thru 5th grade


Wednesday 6:00PM-8:00PM
Thursday 6:00PM-8:00PM
Friday 6:00PM-8:00PM
Saturday 4:30PM-6:30PM Includes Mass

Office phone: 870-932-2529
Please return Registration Fee by May 29, 2019, $15 Registration Fee Checks: Blessed Sacrament

First Name *
First Name
Your answer
Last Name *
Last Name
Your answer
Sex: *
Age *
Grade *
2018-19 School Year
T-Shirt Size *
List Allergies or medical conditions:
List all Food Allergies or Medical Conditions. Leave blank if none.
Your answer
Parents/Guardians’ Name(s): *
Parents/Guardians' First and Last Name
Your answer
Address: *
Street Address, City, State, Zip
Your answer
Home Phone
Ex. (870)000,000 If No Home Phone leave blank.
Your answer
Cell Phone *
ex. (870)000,000 If we cannot contact you at work or not employed leave blank.
Your answer
Please provide an active email address.
Your answer
Name of Emergency Contact if Parent can not be reached. *
List the First, Last Name of Emeregency Contact other than parents.
Your answer
Relationship to Participant *
ex. Cousin, Grandparent, Friend, etc.
Your answer
Emergency Contact Phone Number *
ex. (870)000,000
Your answer
I understand that reasonable precautions will be taken to safeguard the health and well being of the participants in this VBS and that I will be notified as soon as possible in the event of an emergency. In the case of sickness or an accident, I authorize and consent the VBS Team, or other associated volunteers of the VBS program to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that myself or other legal guardian(s) cannot be reached. I hereby do release and forever discharge this Diocese, and Parish from all manners of actions, claims which I or the child named above shall or may have for any reason, arising during my child’s attendance of the VBS. Unless other written instruction is submitted, I also consent to allowing my child’s image to be recorded, either by photograph or video, and used during the VBS week or for future advertisement of Parish VBS programs. Any other use will require your further consent. *
Parent/Guardian Signature
Your answer
Date *
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