Highland Park Baptist Church (HPBC) VBS Registration
(please complete one form per child attending)
June 15-19 / Entering K-Entering 5th! 8:45-12:00
We're So Excited To See You At VBS!!!
Child Information
Name*
First Name
Last Name
Address (for future event updates)
*
Street Address preferred please
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Completed*
5 years / Kindergarten
1st
2nd
3rd
4th/Entering 5th
Child's Birthdate (MM/DD/YEAR)*
Child's Age*
Contact Info
Parent/Guardian: First and Last Name
*
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number (If applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email:
example@example.com
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Need to Knows
Please list any allergies we should be aware of: (if none please write "none")
Who will pick up your child at the end of each VBS day?
*
First Name
Last Name
What is their relationship with the child?
*
Please specify any other individuals you give permission to pick up your child: (HPBC will only release children to individuals pre-authorized to pick the child up). Enter YOUR name if you are the only person authorized to pick up your child.
*
First Name
Last Name
Name
First Name
Last Name
Van Permission
Van Permission - Will your child ride the church van to or from VBS?
Yes
No
Please provide the address for where the van will pick the child up.
Medical, Media, and Van Pick Up Release
By clicking "I Agree" below, you affirm the following statement: I, the parent and/or legal guardian of the above named minor do hereby appoint Highland Park Baptist Church (HPBC) to act on my behalf in authorizing emergency medical aid, dental, surgical care and/or hospitalization for this child in the event I cannot be reached. I agree to be financially responsible for all treatment. I give permission for my child's picture to be used in all HPBC publications. I give permission for my child to be picked up by persons indicated on this form.
*
I Agree
Submit
Should be Empty: