Centerville VBS 2024 Registration

Centerville VBS 2024

June 10-14 at Fairgrounds
Child / Children's Information

4yr old PreK to 5th Grade (Based on Fall 2024)
**Child Name (1)

First NameLast Name
Child (1) Birth Date

MonthDayYear
Child (1) Grade (as of Fall 2024)
Child (1) T-Shirt Size
**Child Name (2)

First NameLast Name
Child (2) Birth Date

MonthDayYear
Child (2) Grade (as of Fall 2024)
Child (2) T-Shirt Size
**Child Name (3)

First NameLast Name
Child (3) Birth Date

MonthDayYear
Child (3) Grade (as of Fall 2024)
Child (3) T-Shirt Size
Does child/children have any special needs? (Medical, allergies, dietary). If yes, please describe.
Parent/Guardian Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone
E-mail
example@example.com
Home Parish/Church
Emergency Information
Emergency Contact's Name

First NameLast Name
Emergency Contact's Relationship
Emergency Contact Phone Number
Photo Release for Youth (4yr old PreK through 5th Grade)

As Parent and/or Guardian of the named child/children, the sponsoring churches of Common Ground and Centerville's Summer VBS has my permission to use my child/children's photograph publicly in VBS materials.

I understand the images may be used in print publiccations, online publications, presentations, websites and social media.

I understand no royalty, fee or other compensation shall become paybable to me by reason of such use.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

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Centerville VBS 2024

Child / Children's Information