Outback Rock Registration

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YCON VBS Form

Child's Name *

Date of Birth *

YYYY

Age *

Last grade completed: *

Name of Parent(s) and Phone # *

Address (Street address, City, Zip) *

Do you have a home church?

Allergies or other medical conditions:

Emergency Contact: (Name, Number and Relationship) *

I give Yorktown Church of the Nazarene permission to post pictures or videos of my child on a social platform.

Yes

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I, the legal guardian of the children listed on this form, hereby release the Yorktown Church of the Nazarene its board, staff or volunteers of any liabilities that may happen while participating in Outback Rock VBS put on by the Yorktown Church of the Nazarene. Please sign name below.

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