VBS Registration Form - Cornerstone

VBS Registration Form

Please fill out the form below, if you have any questions please contact us for additional information. Thank you!

Child Participant Information
Participant Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Medical Problems/ Allergies / Special Needs*

Parent's Contact Information
Parent / Guardian's Name*

First NameLast Name
Phone Number (Daytime / Emergency)*

Area CodePhone Number
E-mail*
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Do you currently have a home church?

YesNo
If Yes, where?
Tell us how you learned about VBS at Mountain Home:

Mountain Home Baptist Church WebsiteInternetNewspaperFlyer / PosterInvited by a friend

Liability Information
CONSENT FOR MEDICAL TREATMENT | As the parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

Signature
CONSENT FOR MEDIA RELEASE | I hereby grant the above named church permission to copyright and use photographs/videos taken at VBS of the minor designated above for any purpose of publication or use of advertising.

Signature
Parent/Guardian Signature*

First NameLast Name
By signing and submitting this registraiton form, you understand and agree to all policies.
Today's Date*

MonthDayYear
Comments and/or Questions:
Should be Empty: