Shipwrecked VBS 2018 Child Registration Form
Connect Church VBS is July 16 - 20 6:00pm - 8:30pm. We love having children at Connect. Please take a moment to fill-out the registration form for your child (Children). Thank you, we use this information for follow-up. ConnectChurchPC.com 1101 W. Grand Ponca City, OK 74601 580-762-2367
Connect Church VBS 2018
Child Name *
Your answer
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
VBS is for ages 3 Years Old to 6th grade
Last Grade Completed *
Required
Gender *
Required
Name of Parent or Caregiver *
Your answer
Address *
Your answer
Cell Number of Parent/Caregiver *
Your answer
Email Address *
Your answer
In Case of Emergency Contact (include name and Cell #) *
Your answer
List Allergies or medical conditions *
Your answer
Home Church
Your answer
Please indicate your permission for your child's (children) image. In order to protect our children and youth we use photos and video taped images without names in our print, broadcast and digital publicity---for example, on our website, social media and other forms of communication. FACEBOOK LIVE each evening. *
Required
Signature Area (Parent/Caregiver) Typing Name Serves at Signature
Your answer
Crew # (Church Use Only)
Your answer
Submit
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