2019 VBS Registration Form
Child's Basic Information
Please submit a separate form for each child you wish to register.
Child's First Name *
Your answer
Child's Last Name *
Your answer
Parent/Guardian Name(s) *
Please enter full name(s).
Your answer
Child's Age
VBS is open to all children ages 3 to 11.
Child's Birthdate *
Format: mm/dd/yy
Your answer
Grade Entering
Gender *
Street Address *
Your answer
City *
Your answer
Your answer
Zip Code *
Your answer
Do you need transportation?
Parent/Guardian's E-Mail
Your answer
Parent/Guardian's Phone # *
Example: 215-555-5555
Your answer
Emergency & Pick up Information
Emergency Contact Name and Relationship *
Please enter emergency contact name and relationship to child.
Your answer
Emergency Contact Phone # *
Your answer
Alternate Pickup #1 - Name
Your answer
Alternative Pickup #1 - Phone
Your answer
Alternate Pickup #2 - Name
Your answer
Alternative Pickup #2 - Phone
Your answer
Is there anyone who should not pick up your child?
If yes, please enter the full name.
Your answer
Tell Us About Your Child
School Name
Enter the child's school name.
Your answer
Church Name
If your family attends a church regularly, please enter the church name.
Your answer
Food Allergies
If this child has food allergies or sensitivities, please list them here.
Your answer
Special Needs?
Does this child have special needs or in need of a 1:1 buddy?
Other Needs
Is there anything else we need to know that will help this child the week of VBS?
Your answer
First aid if needed? *
May we administer first aid as needed?
May we take photos of the child? *
Throughout the week we take lots of fun pictures for our slideshow and webpage. The child's name will not be published. May we have your permission to use this child's photo?
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