Vacation Bible School
Circleville Christian Church
Student Information
Name #1
First Name
Last Name
Grade (all welcome)
If Pre-K, please register child's age. This will allow us to make sure that crafts and activities are age appropriate.
Name #2
First Name
Last Name
Grade (all welcome)
If Pre-K, please register child's age. This will allow us to make sure that crafts and activities are age appropriate.
Name #3
First Name
Last Name
Grade (all welcome)
If Pre-K, please register child's age. This will allow us to make sure that crafts and activities are age appropriate.
Parent/Guardian/Grandparent
First Name
Last Name
Adult Email Address
Adult Phone Number
Please enter a valid phone number.
Are you new to Circleville Christian Church?
Yes
No
I've been to other youth events at Circleville Christian Church
Other
Residence Information
This address will be utilized to relay upcoming children's events and registrations.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 1
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact 2
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Physician and Medical Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
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