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 of Child*
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, & Transportation 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: