VBS 2021 Child Registration Form
VBS is available for children 3 years old up to just completed 8th grade and will be held June 7th-10th from 6:30-8:30pm
How many children are you registering?
*
1
2
3
4
Child Information
Please complete the following information for each child you are registering
First Child
Child's Name
*
First Name
Last Name
Child's Gender
*
Male
Female
Child's Age
*
Child's Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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31
Day
Please select a year
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2023
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Year
Last Grade Completed
*
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Medical or other information we may need to know about the child (including food allergies).
*
Second Child
If you are not registering another child, please skip this section
Child's Name
First Name
Last Name
Child's Gender
Male
Femal
Child's Age
Child's Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
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14
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28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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2009
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Last Grade Completed
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Medical or other information we may need to know about the child (including food allergies).
Third Child
If you are not registering another child, please skip this section
Child's Name
First Name
Last Name
Child's Gender
Male
Femal
Child's Age
Child's Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Last Grade Completed
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Medical or other information we may need to know about the child (including food allergies).
Fourth Child
If you are not registering another child, please skip this section
Child's Name
First Name
Last Name
Child's Gender
Male
Femal
Child's Age
Child's Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Last Grade Completed
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Medical or other information we may need to know about the child (including food allergies).
Parent/Guardian Information
Children must be picked up from VBS by an approved person(s) of at least 16 years of age unless a previous arrangement has been made with Berea Christian Church
Parent/Legal Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Emergency Contact (other than parent/guardian listed above)
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Emergency Contact's Relationship to the child (children)
*
Mother
Father
Grandmother
Grandfather
Aunt
Uncle
Other
If Other, please explain below
Names of Persons to which the child (children) may be released to each night after VBS (Please provide at least two)
*
First Name
Last Name
Full Name
*
First Name
Last Name
Full Name
First Name
Last Name
Full Name
First Name
Last Name
Are there any persons to which the child (children) may NOT be released to?
*
Yes
No
Who may you child (children) NOT be released to?
Media Release
By clicking the box below, I hereby give permission for photographs and/or video in which my child appears in to be used by the church in printed and/or electronic media, including the church's website or Facebook page
I Agree
Submit
Should be Empty: