Language
English (US)
Grace Bible Church
2022 VBS
Student #1
*
Age
*
Grade Completed
*
Birthdate
*
/
Month
/
Day
Year
Student #2
Age
Grade Completed
Birthdate
/
Month
/
Day
Year
Student #3
Age
Grade Completed
Birthdate
/
Month
/
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Regularly attend church?
Yes
Where?
Parent(s)/Guardians(s)
*
Phone (home/cell)
*
Please enter a valid phone number.
Phone (work)
Please enter a valid phone number.
Emergency Contact (other than parent)
Emergency Phone
Please enter a valid phone number.
Invited by
Medical Release
Doctor's Name
Doctor's Phone
Please enter a valid phone number.
Child's Name
Known Conditions
Allergies
Additional Info
1
2
3
In case of a medical emergency*, I give my permission to the physician selected by the Space Probe Director(s) to secure proper treatment and/or hospitalization for children listed above.
* The Space Probe Director(s) will make every attempt to reach the parent/legal guardian listed, or the emergency contact given on your registration form.
Parent/Guardian Signature
*
Clear
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