VBS Youth Registration Form
Child's First Name:
*
Child's Last Name:
*
Child's Birthdate:
*
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Month
-
Day
Year
Date
Child's Age:
*
Child's Grade (2025-2026 School Term):
*
Allergies/Special Needs:
*
Parent/Guardian's First Name:
*
Parent/Guardian's Last Name:
*
Parent/Guardian's Mobile Number:
*
Parent/Guardian's Work Number (Include Ext.):
*
Parent/Guardian's Email Address:
*
Emergency Contact First Name (Other Than Parent/Guardian):
*
Emergency Contact Last Name (Other Than Parent/Guardian):
*
Emergency Contact Mobile Number (Other Than Parent/Guardian):
*
List The Name(s) and Relationship of Those Eligible to Pick Up Your Child:
*
Do you grant Restoration Church Permission to use your child's name, image, or likeness in any media publication, promotion, or any form of advertisement?
Yes
No
Parent/Guardian Electronic Signature (Please type your First and Last Name):
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: