VBS 2022 Registration Form

VBS 2022 Registration Form
Child's Name *

First Name Last Name
Child Gender *

Male Female
Date of Birth *

Month Day Year
Date
Next Grade Level (Grade Entering) *
Alleries, Medical Conditions or Special Needs? *

Yes No
If yes, describe:
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contacts

Please list 2 emergency contacts.
Name of Parent/Guardian #1 *

First Name Last Name
Phone Number (Parent/Guardian #1) *
Please enter a valid phone number.
Name of Parent/Guardian #2 *

First Name Last Name
Phone Number (Parent/Guardian #2) *
Please enter a valid phone number.
Email *
example@example.com
Home Church
Photo Release: I give permission for photographs of the persons listed above to be used in publications of Raiford Road Church (including the church website and Facebook/Instagram pages.) I understand that these photos may be viewed by anyone but no identifying information will be displayed. *

Yes, I give permission No, I do not give permission
Signature *

Clear
Should be Empty:

Emergency Contacts