Berwick Church of Berwick VBS Registration Form

Berwick Church of Berwick VBS Registration Form

(One per child)
Child's Name

First NameLast Name
Child's Age
Birth Date

MonthDayYear
School Grade Entering
Name of Parents/Guardians

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Parent/Guardian's Cell Phone Number

Area CodePhone Number
Home Email Address
Home Church
ALLERGIES OR OTHER MEDICAL CONDITIONS
IN CASE OF EMERGENCY, CONTACT:

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child
OTHER THAN PARENT, in case of EMERGENCY, CONTACT:

First NameLast Name
Phone Number

Area CodePhone Number
NAME OF THOSE WHO MAY PICK UP CHILD:
Permission for child to be photographed and/or videotaped?

YesNo
Permission for child's photo/video to be used in newspaper or church newsletter and Facebook page?

YesNo
PARENT/GUARDIAN SIGNATURE

Clear
Date
Should be Empty: