VBC Registration 2019
Email address *
Kid's First Name: *
Your answer
Kid's Last Name: *
Your answer
Kid's Birthdate *
MM
/
DD
/
YYYY
City, State, Zip *
Your answer
Grade Completed *
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Phone *
Your answer
Street Address *
Your answer
Emergency Contact Name (and relation to child) *
Your answer
Emergency Contact Number *
Your answer
Special Needs, Allergies, Medication, etc.
Your answer
List 2 persons that have permission to pick up your child. (with phone number)
Person 1
Your answer
Person 2 (with phone number)
Your answer
Shirt Sizes Needed
please list -- size range is Youth Small - Youth Large, Adult Small - Adult 3XL
Your answer
Photo/Video Release - by saying “yes”, I give permission to the church to take (and post) pictures and videos of my child. *
A copy of your responses will be emailed to the address you provided.
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