Parkgate VBS 2022 Child Registration

CHILD REGISTRATION

Please complete this form as thoroughly as possible. You may register up to 5 children from the same family using this form.

Family Last Name *

Parent/Guardian 1 *

First Name Last Name

Parent/Guardian 2

First Name Last Name

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Where does your family attend church? *

Parkgate Community Church Don't attend

How did you hear about our VBS? *

How many children are you registering to attend VBS? *

1 2 3 4 5

CHILD #1 INFORMATION

Child's Name *

First Name Last Name

Gender *

Male Female

Fall 2022 Grade/Age *

Age 3 (by July 10) Age 4 Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade

Children must be potty-trained in order to attend VBS. Thanks!

Preferred Name

Birth Date *

Month Day Year

In the box below, you may write the name of a friend your child would like to be in class with. While we do our best to accomodate these requests, we cannot make any guarantees.

Friend's Name

First & Last Name

CHILD #2 INFORMATION

Child's Name *

First Name Last Name

Gender *

Male Female

Fall 2022 Grade/Age *

Age 3 (by July 10) Age 4 Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade

Children must be potty-trained in order to attend VBS. Thanks!

Preferred Name

Birth Date *

Month Day Year

In the box below, you may write the name of a friend your child would like to be in class with. While we do our best to accomodate these requests, we cannot make any guarantees.

Friend's Name

First & Last Name

CHILD #3 INFORMATION

Child's Name *

First Name Last Name

Gender *

Male Female

Fall 2022 Grade/Age *

Age 3 (by July 10) Age 4 Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade

Children must be potty-trained in order to attend VBS. Thanks!

Preferred Name

Birth Date *

Month Day Year

In the box below, you may write the name of a friend your child would like to be in class with. While we do our best to accomodate these requests, we cannot make any guarantees.

Friend's Name

First & Last Name

CHILD #4 INFORMATION

Child's Name *

First Name Last Name

Gender *

Male Female

Fall 2022 Grade/Age *

Age 3 (by July 10) Age 4 Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade

Children must be potty-trained in order to attend VBS. Thanks!

Preferred Name

Birth Date *

Month Day Year

In the box below, you may write the name of a friend your child would like to be in class with. While we do our best to accomodate these requests, we cannot make any guarantees.

Friend's Name

First & Last Name

CHILD #5 INFORMATION

Child's Name *

First Name Last Name

Gender *

Male Female

Fall 2022 Grade/Age *

Age 3 (by July 10) Age 4 Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade

Children must be potty-trained in order to attend VBS. Thanks!

Preferred Name

Birth Date *

Month Day Year

In the box below, you may write the name of a friend your child would like to be in class with. While we do our best to accomodate these requests, we cannot make any guarantees.

Friend's Name

First & Last Name

ADDITIONAL FAMILY INFORMATION

Do any of your children have dietary restrictions? If yes, please list the child's name and give details in the box below. *

Yes No

Dietary Restrictions

Do any of your children have allergies? If yes, please list the child's name and give details in the box below. *

Yes No

Allergies

Do any of your children have other special needs we should be aware of (i.e., epilepsy, autism, behavioral concerns, etc.)? If yes, please list the child's name and give details in the box below. *

Yes No

Other Special Needs

EMERGENCY CONTACT INFORMATION

Please provide information for two emergency contacts for your child the week of VBS. This may be the parent/guardian indicated above or another individual providing your child care during VBS.

Contact #1 Name *

First Name Last Name

Contact #1 Phone *

Area Code Phone Number

Relationship to Child *

Contact #2 Name *

First Name Last Name

Contact #2 Phone *

Area Code Phone Number

Relationship to Child *

E-MAIL

During Vacation Bible School, we utilize e-mail as our principal means of communication with families. You'll receive a special VBS Newsletter each morning recapping the previous evening's events and previewing any special information for the day to come. These e-mails will come from chaines@parkgate.org and vbs@parkgate.org, so please add these addresses to your safe senders list. You will also receive a few e-mails in the weeks leading up to Vacation Bible School.

E-mail *

PHOTO RELEASE POLICY

Parkgate Community Church will be photographing/filming students throughout the week at VBS. By selecting yes, I understand that my children's photographs may be presented in an array of multimedia formats both online and in print. This includes our Facebook Page, where you may be taggged.

I recognize that by selecting no, my children will not be included in their class group photo.

Do you agree to Parkgate Community Church's Photo Release Policy? *

Yes No

EMERGENCY TREATMENT

By typing my name in the box below, I grant all of the children registered on this form permission to participate in all VBS activities. In the event of an emergency where medical treatment is required, I give my permission to the Parkgate Community Church staff and/or VBS volunteers to obtain the services of a licensed physician. In the event that I cannot be readily contacted, I hereby authorize any medical teatment that may be necessary to be administered to my children. I understand that I will be responsible for any costs incurred. I recognize that Parkgate Community Church will not be held responsible for any injuries occured during VBS.

Electronic Signature: *

First Name Last Name