Roar VBS Registration
Bethel Lutheran Church, Bartonville, IL
July 14-18, 2019
Email address *
Child's Name *
Your answer
Child's Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade Entering *
Name of Parents *
Your answer
Home Address (please include city and zip) *
Your answer
Phone Number *
Your answer
Phone number type
Preferred email address
Your answer
Name(s) of person(s) authorized to pick child up from VBS *
We will be implementing a sign-out procedure this year. Please list first and last names of all individuals that have permission to pick up your child.
Your answer
I give my child permission to walk home from VBS.
If your child will be walking home from VBS, please type your signature below.
Your answer
Allergies/Medical/Special Needs *
Please explain in detail any special needs, allergies, or medical conditions of which we need to be aware. Include symptoms to watch for, actions to be taken, specific instructions for the administration of any needed medications (including epi-pens) and follow-up procedures.
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship to Child *
Your answer
Photo Release *
I give permission for my child's picture to be used for social media publicity for Bethel Lutheran. I understand that the church will not display the child's picture along with his/her name. (Please type your name below to sign)
Your answer
A copy of your responses will be emailed to the address you provided.
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