VBS 2026 | June 22-26 6PM-8PM
Emerald Crossing | Moundsville Baptist Church
Child's Name:
*
First Name
Last Name
Child’s Birthday
-
Month
-
Day
Year
Date
Guardian's Name:
*
First Name
Last Name
Address
*
Street Address
Street Address 2 (if needed)
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Grade Child is Going Into:
*
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Emergency Contact:
*
Rows
Full Name
Relation
Contact Number
1 (Primary)
2 (Secondary)
3 (optional)
Authorized People for Pick-Up:
*
Rows
Full Name
Relation
Contact Number
1
2
3
4
5
Allergies/Special Needs:
*
Permission to post photography of the event your child is in on our social media accounts?
*
Yes
No
Additional Information:
Submit
Should be Empty: