Vacation Bible School - June 5-9, 2023                  ***9 a.m. - 12 noon*** at United Christian Church
Thanks for using our Online Registration Form! You may complete one form for your entire family.
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Email *
Family Name *
Primary Contact Information (name, phone, and email) where they can be reached during VBS hours *
Alternate Emergency Contact(s) Name(s) and Phone Number(s)  *

Full Name(s) of Individual(s) Authorized to Pick up my Child (must be 18 years of age or older and present valid ID)

 *
If volunteering at VBS, list Adult Volunteer Name(s)
Home Address *
Child/Youth #1 Name  (or "VOL" if participating as a UCC Youth Volunteer) *
Date of Birth:
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Age/Grade Completed as of June 5th
Clear selection
Child/Youth #2 Name
Date of Birth:
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DD
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YYYY
Age/Grade Completed as of June 5th
Clear selection
Child/Youth #3 Name
Date of Birth:
MM
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DD
/
YYYY
Age/Grade Completed as of June 5th
Clear selection
Child/Youth #4 Name
Date of Birth:
MM
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DD
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YYYY
Age/Grade Completed as of June 5th
Clear selection
Medical Insurance Company, Policy/Group Number, Member Number *
Primary Care Physician/Phone Number *

List any conditions you feel we need to know to properly care for your child/children. Examples include food or other allergies, anxiety, or a physical impairment.

 *

Should a child/children require any medical attention during this period, list any special instructions that might be required (e.g. current medications, allergies to drugs, rare blood type).


Please let us know any additional information that might help us make your child's/children's VBS experience more comfortable:
Understanding that no names of children will be used, please check all that apply regarding photography during the week of VBS (Volunteers, please check "NA"): *
I understand that a Parent/Guardian will be required to sign a Permission to Participate, Medical Treatment Consent, and Release, Waiver, and Indemnity Agreement in order for their child/children to participate in VBS.

The Agreement will be sent in advance to the email address provided at the top of this form. You can either print/complete it and turn it in at the time of check-in, or you can complete an Agreement form available at check-in.
*
Required
If you're not a church member or regular attendee, please let us know how you’re connected to UCC Austin or how you found out about our VBS program (e.g. former member, friend of_____, cousin of_____, grandchild of_____)
We depend on volunteers to make our week a success! When can you help? Please check all that apply :) *
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