Youth Registration Form
Please Note: Separate registration forms must be completed for each child participating in Vacation Bible School.
Child’s Name
*
First Name
Last Name
Gender
*
Male
Female
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Last Grade Completed
*
Please Select
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Parent/ Guardian Information
Name of Parent or Guardian
*
First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Information
*Allergies, Medical Conditions, or Special Needs (If none, put N/A)
*
*In Case of Emergency, Contact
*
*Emergency Contact Relationship to Child
*
*Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to photograph/video your child?
*
Yes
No
If so, do we have permission to post photographs/videos of your child on social media?
*
Yes
No
Please list all persons authorized to pick up your child and their relationship to the child. (John Doe-neighbor). In the event it is not a parent, please note a valid I.D. will be required at sign out.
*
Do you currently have a home church?
Yes
No
If Yes, Where?
Liability Waiver and Release
I understand and acknowledge that I have voluntarily chosen to allow myself/my child to participate in Vacation Bible School hosted by Mossy Living Word Church. I understand that all reasonable safety precautions will be taken by the staff and volunteers of Mossy Living Word Church during this event. I understand that participation in VBS may involve activities that carry a risk of injury, and I assume full responsibility for any such risks. I agree not to hold Mossy Living Word Church, its staff, volunteers, or affiliates liable for any accident, injury, or illness that may occur during participation in Vacation Bible School.
Signature
*
Continue
Continue
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