VBS REGISTRATION FORM "Gearing Up For Life's Big Game"

VBS REGISTRATION FORM "

"Gearing Up for Life's Big Game"
Institution Name
STUDENT INFORMATION
Name

First NameLast Name
Gender
Age *
Grade Completed by Child *
Home Church (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name & Age of Siblings Enrolling in VBS *
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*
YesNo
Please list all medical concerns -- or type "none" if there are none*
Additional Information
Please list the names of any other children (friends or family) that you would like placed in the same class as this child
YesNo
Yes ALL ActivitiesNo ALL ActivitiesField Day Activities but NO Water Games
By submitting this form, I ackowledge I have read and understand the above information.
Parent's/Guardian's Email Address:
Signature
Should be Empty:

VBS REGISTRATION FORM "