VBX Registration
Bayside of Placerville VBX Registration for rising PreK-5 Graders.
NEW! This year potty trained three year olds and older are welcomed to join us in the own VBX classroom.
VBX is June 24-27 6:30-8:30pm at Bayside Church of Placerville
Contact Heather Cook at 530-626-7288 for more information.
Email address *
Student Registration
Student's Name *
Your answer
Date of Birth *
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Street Address: *
Your answer
Grade Completed in 2018 *
Allergies/Medical Conditions/Special Needs/Concerns:
Your answer
Emergency Contact Information
Parent/Guardian Name *
Your answer
Phone Number *
Your answer
Alternate Pick-Up Person & Phone *
Your answer
Alternate Emergency Contact Person: Name & Phone Number *
Your answer
By registering for this event you are agreeing to abide by the rules and understandings of the VBX at Bayside of Placerville. You understand that attendance at VBX is based upon mutual respect and consideration between campers and staff. The VBX staff has permission to obtain emergency medical and/or dental care for my child should they be unable to reach me. For promotional purposes, videos and photographs are taken at Bayside of Placerville events. Your registration constitutes permission for Bayside of Placerville to use your child’s likeness in all promotional material. *
A copy of your responses will be emailed to the address you provided.
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