Vacation Bible School Registration Form 2022

Vacation Bible School Registration Form

Saturday October 22, 2022 9:30 am - 12:30 pm
Child's Information
Child's Name *

First Name Last Name
Child's Age *
Gender *

Male Female
Child's Birthdate *

Month Day Year
Date
Does your child attend school? *

Yes No
If yes, what school? *
What grade will your child be entering in the fall? *
Parent/Guardian's Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (in case of emergency) *
Please enter a valid phone number.
Health Information
Are there any activities that your child should be restricted from doing? *
Are there any physical, mental or other condition that would require special attention while attending VBS? *
Please list any allergies that we should be aware of: (i.e., bees, nuts, dairy, etc.) *
Are there any special dietary needs we need to know about? *
Emergency Contact other than parent/guardian: *

First Name Last Name
Emergency Contact's Phone number: *
Please enter a valid phone number.
Church Information
Do you attend church regularly? *

Yes No
If yes, where do you attend church? *
If no, would you like further information on our church and our children's programming? *
How did you hear about Liberty Bible Church's VBS program? *
Is this your first time attending VBS at Liberty Bible Church? *

Yes No
Child Release
Please list the ONLY people, including parents/guardians and emergency contacts, to whom your child can be released. *
By hitting submit and typing your initials, you agree that you are the parent or legal guardian of the above named child, and are over the age of 18.

In case of medical emergency or general medical care, I give consent for medical treatment for the aboved named child by authorized personnel.

I understand that the above named child will only be released ot the names listed above, and an update may be made at physical registration at the start of VBS.

I certify that my child has my permission to attend VBS at Liberty Bible Church and may participate in all activities. I authorize Liberty Bible Church to use my child's picture, tesitmony and video in any promotional material (web, print or media) without the use of last names or location of living address.

I will not hold Liberty Bible Church or any of its affiliates, officers, members, or VBS staff responsible for injury to my child and also know that my child will be cared for in the event of any injury.
Please initial below: *
Electronic Signature, please type full legal name. *
Should be Empty:

Vacation Bible School Registration Form

Child's Information

Health Information

Church Information

Child Release