VBS-Our Redeemer Lutheran Church-Chugiak, AK
June 12-16 , 9:30 am-12:00 pm
Name of the Child
First Name
Last Name
Age
Gender
Male
Female
Grade Level
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Is he/she carrying an Epi-pen at all times?
Yes
No
Does your child have any allergies?
Yes
No
What are the allergies of your child?
Does your child have any medical condition that we should be aware of?
Yes
No
What is this medical condition? Please elaborate below:
Pick Up Authorization
Authorized person/s to pickup your child after VBS
Full Name 1
First Name
Last Name
Relationship
Full Name 2
First Name
Last Name
Relationship
Emergency Contact Information
Emergency Contact 1
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Emergency Contact 2
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Photo/Media Release
Would it be okay if we take photos and videos of the participant during the activity which could be posted on our social media account or website?
Yes
No
Submit
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