VBS Registration 2022
Please complete one registration form per child. Program is for children age 4 through entering 6th grade. Please note, you will still need to accompany your child to registration on the first night of VBS so that we can obtain your signature on this form. Thank you! We look forward to meeting your family!
Sunday, July 10th - Thursday, July 14th
6:00pm - 8:00pm
North Valley Baptist Church
1300 Old Plank Road Mayfield, PA 18433 (570)592-5259
Child's Name
*
First Name
Last Name
Age
*
Grade Entering in Fall
*
Select Grade
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Parent/Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Parent/Guardian Email
example@example.com
Emergency Contact
*
person who can be reached during VBS program
Relationship to child
*
Emergency Contact Phone #
*
-
Area Code
Phone Number
Child's Food Allergy/Health Condition that may limit participation in program
please explain anything we would need to know
My child may be released at the close of VBS to myself and the following other adults. Please indicate name and relationship to child
Your child will only be allowed to leave with adults you have permitted and the adults picking up your child will need to sign him/her out before leaving
Please Note:
You will need to accompany your child to registration on the first night of VBS so that we can obtain your signature(s) on this form and our waiver form. Your child will not be allowed to participate in the program without a parent/guardian signature. We look forward to meeting you!
Submit
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