Country Acres Baptist Church: Vacation Bible School Registration
Date: June 11th-15th
Time: 9:00 am to Noon
Place: 8810 W. 10th Street N

If you are registering more than four children, then you will need to fill out another registration form.
Name of child, date of birth, and last grade completed NEED to be filled out for each child you register.

1st Child's Last Name *
Your answer
First Name *
Your answer
Last Grade Completed *
Date of Birth *
MM
/
DD
/
YYYY
Medical Information (include any food allergies)
Your answer
2nd Child's Last Name
Your answer
First Name
Your answer
Last Grade Completed
Date of Birth
MM
/
DD
/
YYYY
Medical Information (include any food allergies)
Your answer
3rd Child's Last Name
Your answer
First Name
Your answer
Last Grade Completed
Date of Birth
MM
/
DD
/
YYYY
Medical Information (include any food allergies)
Your answer
4th Child's Last Name
Your answer
First Name
Your answer
Last Grade Completed
Date of Birth
MM
/
DD
/
YYYY
Medical Information (include any food allergies)
Your answer
Parent/Guardian *
Your answer
Phone Number *
Your answer
E-mail *
Your answer
Address (including city, state, and zip code) *
Your answer
Mailing Address (if different)
Your answer
Who may pick up your child/children at the end of each VBS day? *
Your answer
If your family attends another church, which church are you coming from?
Your answer
How did you hear about our church?
Your answer
Emergency/Medical Information
Emergency Contact (name and phone number) *
Your answer
Family Physician & Phone Number *
Your answer
Insurance Provider *
Your answer
Group/Policy # *
Your answer
Terms and Conditions
May we have permission to photograph your child/children? *
1.) I understand that my child will be participating in physical activities. As with any physical activity, there is a risk of injury. I fully accept this risk and hold harmless from any legal liability Country Acres Baptist Church and any persons involved in the VBS ministry. 2.) In the event of an emergency that requires medical treatment for the above name child(ren), I understand every effort will be made to contact me or my emergency contact. However, if I/we cannot be reached I give my permission to CABC and the Children's Ministry Director to secure the services of a licensed physician to provide the care necessary for my child's well-being. I assume responsibility for all costs connected to any accident or treatment of my child. I grant permission for my child to be transported with an adult by CABC or private vehicle to and from CABC and other events. Any such event will be clearly communicated with me beforehand. *
Required
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