Vacation Bible School Registration Form

Zion Lutheran Church & School Vacation Bible School 2022 Child Registration Form VBS 2022 Dates: Monday June27-Friday July 1st from 6:00pm-8:00pm Location: Zion Lutheran Church & School, 14735 County Road 153 Cologne, MN 55322. Registration Cost: Free (Offerings will be taken for mission work)

Institution Name

STUDENT INFORMATION

Last Name *

First Name *

M.I.

Birth Date *

Month Day Year

Gender

Grade completed by June 2020 *

Have you previously attended VBS?

Yes No

If yes, what year?

Home Church (if any)

Street Address *

Street Address Line 2 *

City *

Postal Code *

Primary Phone Number *

Secondary Phone Number

Siblings Enrolled in VBS 2020

First Name Last Name

EMERGENCY CONTACTS Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.

Primary Guardian *

First Name Last Name

Relationship to child *

Phone Number *

Area Code Phone Number

Alternate Guardian #1 *

First Name Last Name

Relationship to child *

Phone Number *

Area Code Phone Number

Alternate Guardian #2

First Name Last Name

Relationship to child

Phone Number

Area Code Phone Number

Medical Information

Please list all allergies -- or type "none" if there are none *

Does your child carry an epi-pen? (please note: if yes, it is the responsibilty of the child's guardian to ensure the child has the epi-pen at every drop off and pick up) *

Yes No

Please list all medical concerns -- or type "none" if there are none *

Additional Information

Please list the names of any other children (friends or family) that you would like placed in the same class as this child

VBS photos/videos are taken for promotional purposes related to Zion Lutheran Church and Vacation Bible School. These pictures appear in various media outlets such as The Norwood Times or Waconia Patriot and our facebook page and webpage. Do you allow your child to be included in these photos/videos? *

Yes No

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