Breaker Rock Beach Vacation Bible School Registration Form

Breaker Rock Beach Vacation Bible School Registration Form
Institution Name
STUDENT INFORMATION
Name

First NameLast Name
Birth Date *

MonthDayYear
Date
Gender
Grade completed by *
Have you previously attended VBS?

YesNo
Home Church (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACTS
Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.
Primary Guardian*

First NameLast Name
Relationship to child*
Phone Number*
Format: (000) 000-0000.
Alternate Guardian #1*

First NameLast Name
Relationship to child*
Phone Number*
Format: (000) 000-0000.
Alternate Guardian #2

First NameLast Name
Relationship to child
Phone Number
Format: (000) 000-0000.
Medical Information
Please list all allergies -- or type "none" if there are none*
Does your child carry an epi-pen? (please note: if yes, it is the responsibilty of the child's guardian to ensure the child has the epi-pen at every drop off and pick up)*

YesNo
Please list all medical concerns -- or type "none" if there are none*
Additional Information
VBS photos/videos are taken for promotional purposes related to Southeast Baptist Church and Vacation Bible School. These pictures may appear in various media outlets such as the news and our facebook page and webpage. Do you allow your child to be included in these photos/videos?*

YesNo
By submitting this form, I ackowledge I have read and understand the above information.
Signature
Should be Empty:

Breaker Rock Beach Vacation Bible School Registration Form

Medical Information

Additional Information