VBS Registration Form
Please fill out a separate registration form for all children attending.
Child's Name
*
First and Last
Child's age
*
Date of birth
*
/
Month
/
Day
Year
Date
Name of parents/guardians
*
First and Last
Street address
*
City
*
State
*
Zip
*
Parent/guardian's cell phone
*
Parent/guardian's email address
*
example@example.com
Custodial arrangement if applicable
Allergies or other medical conditions (i.e. diabetes)
In case of emergency, contact
*
Emergency contact phone number
*
Emergency contact relationship to child
*
Any siblings under the age of 4 interested in the play area? If so, how many? (Parents must be present)
Request my child to be grouped with the following child(ren)
By signing below, you give permission to call 911 in case of an emergency. Parent/guardian signature
Photographs will be taken during VBS. My signature indicates I am giving permission for my child's photo to be taken.
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