Vacation Bible School Registration
Student's Name
Your answer
School Attending
Your answer
Date of Birth
MM
/
DD
/
YYYY
Last school grade completed
Your answer
Special needs/Allergies/Medical Information/Other
Your answer
Parent/Family/Guardian Name
Your answer
Is this a grandparent
Address including city, state and zip code
Your answer
Mother cell
Your answer
Father cell
Your answer
Email address
Your answer
Phone number home
Your answer
Phone number work
Your answer
May we contact you at work
Home church if any
Your answer
Emergency Medical Information: Insurance Company
Your answer
Policy Number
Your answer
Emergency Contacts/ Name and Phone Number
Your answer
Emergency Contacts/Name and Phone Number
Your answer
Name of person(s) who may pick up this child from VBS
Your answer
Image Release Form/ Photo Release Our Lady of Lourdes Church/VBS has my permission to use my child's photograph publicly in VBS materials. I understand the images may be used in print publications, presentations, websites and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. *
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