2026 VBS Registration Form

2026 VBS Registration Form
TO BE HELD AT: Pohick Episcopal Church 9301 Richmond Highway Lorton, Virginia 22079

Beginning at age 3 (only if potty-trained) - Grade 5* Monday - Friday 9:00 A.M. - 12:00 Noon

*Grade that they just completed

IT IS NECESSARY FOR THE DAILY SESSIONS TO BEGIN PROMPTLY AT 9 A.M.

Pohick Church invites children ages 3 through 5th grades to Vacation Bible School July 13-17, 2026 from 9 am to noon. The theme is Snowball Mountain Challenge; with Jesus we can do all things. Students will enjoy an interactive, energizing, Bible-based good time where they will become Challengers and will learn that with the strength God provides through Jesus, they can do more than they ever dreamed they could do. With this understanding, children will be invited to share the good news of Jesus and share the love and strength God offers with everyone, everywhere, every day. Each day will include exciting new music, creative crafts, fun recreation, tasty snacks, and memorable Bible stories. Along the way, the Challengers will hear about our mission project as they respond to a call for action!

The 6th – 12th grade students are welcome to come and be assistants and aides!

Anyone who is interested in helping in any way, please contact Susan Pehrsson at 703-339-6572 or spehrsson@pohick.org
Parent/ Guardian Name*

First NameLast Name
Parent Cell Number*
Please enter a valid phone number.
Parent E-Mail*
example@example.com
Parent Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Children Registering for VBS

- Child 1's Name
  
  First NameLast Name
- Grade Completed This Year
- Child's Date of Birth
  
  MonthDayYear
  Date
- PERMISSION FOR EMERGENCY CARE
  
  THE CHURCH HAS MY PERMISSION TO CALL ANOTHER PHYSICIAN IN AN EMERGENCY WHEN FAMILY PHYSICIAN OR I CANNOT BE CONTACTED
- Name of Family Physician
- Physician Telephone
- Is your child allergic to medication?
- If yes please list which medications:
- Any other allergies: food allergies, bee stings, etc?
- Under physician's care?
- Under medication now?
- Child 2s Name
  
  First NameLast Name
- Grade Completed This Year
- Child's Date of Birth
  
  MonthDayYear
  Date
- PERMISSION FOR EMERGENCY CARE
  
  THE CHURCH HAS MY PERMISSION TO CALL ANOTHER PHYSICIAN IN AN EMERGENCY WHEN FAMILY PHYSICIAN OR I CANNOT BE CONTACTED
- Name of Family Physician
- Physician Telephone
- Is your child allergic to medication?
- If yes please list which medications:
- Any other allergies: food allergies, bee stings, etc?
- Under physician's care?
- Under medication now?
- Child 3's Name
  
  First NameLast Name
- Grade Completed This Year
- Child's Date of Birth
  
  MonthDayYear
  Date
- PERMISSION FOR EMERGENCY CARE
  
  THE CHURCH HAS MY PERMISSION TO CALL ANOTHER PHYSICIAN IN AN EMERGENCY WHEN FAMILY PHYSICIAN OR I CANNOT BE CONTACTED
- Name of Family Physician
- Physician Telephone
- Is your child allergic to medication?
- If yes please list which medications:
- Any other allergies: food allergies, bee stings, etc?
- Under physician's care?
- Under medication now?
- Child 4's Name
  
  First NameLast Name
- Grade Completed This Year
- Child's Date of Birth
  
  MonthDayYear
  Date
- PERMISSION FOR EMERGENCY CARE
  
  THE CHURCH HAS MY PERMISSION TO CALL ANOTHER PHYSICIAN IN AN EMERGENCY WHEN FAMILY PHYSICIAN OR I CANNOT BE CONTACTED
- Name of Family Physician
- Physician Telephone
- Is your child allergic to medication?
- If yes please list which medications:
- Any other allergies: food allergies, bee stings, etc?
- Under physician's care?
- Under medication now?
- Child 5's Name
  
  First NameLast Name
- Grade Completed This Year
- Child's Date of Birth
  
  MonthDayYear
  Date
- PERMISSION FOR EMERGENCY CARE
  
  THE CHURCH HAS MY PERMISSION TO CALL ANOTHER PHYSICIAN IN AN EMERGENCY WHEN FAMILY PHYSICIAN OR I CANNOT BE CONTACTED
- Name of Family Physician
- Physician Telephone
- Is your child allergic to medication?
- If yes please list which medications:
- Any other allergies: food allergies, bee stings, etc?
- Under physician's care?
- Under medication now?
- Child 6s Name
  
  First NameLast Name
- Child's Date of Birth
  
  MonthDayYear
  Date
- Grade Completed This Year
- PERMISSION FOR EMERGENCY CARE
  
  THE CHURCH HAS MY PERMISSION TO CALL ANOTHER PHYSICIAN IN AN EMERGENCY WHEN FAMILY PHYSICIAN OR I CANNOT BE CONTACTED
- Name of Family Physician
- Physician Telephone
- Is your child allergic to medication?
- If yes please list which medications:
- Any other allergies: food allergies, bee stings, etc?
- Under physician's care?
- Under medication now?

Consent to Use Photographs of Minors in Official Church. Publications of Pohick Church

For the purpose of promoting its ministries, Pohick Church will often take photographs of children and staff, or photographs in which children may be involved with others. In order to understand the wishes of parents and/or guardians with respect to the use of these photographs in official publications, this form must be completed and returned with your child's registration information.

For clarity, the term "Pohick Church" as used herein refers to Pohick Church staff and volunteers; "photograph(s)" to both still photographs and videotape footage; "child" to a child who is a minor; and "official publications" to Pohick Church-sanctioned print publications, online publications, presentations, websites, and social media.
*************************************************************************
I understand that photographs of my child may be used in official publications. I also understand that no royalty, fee or alter compensation shall become payable to me by reason of such use. I understand that no other personal identification of my child such as name, age, or grade, will be disclosed.
Consent

For official publications, I consent for Pohick Church to use photographs of my child taking part in church-sponsored activities and/or learning experiences.For official publications, I DO NOT consent for Pohick Church to use photographs of my child taking part in church-sponsored activities and/or learning experiences.
Should be Empty:

2026 VBS Registration Form

Consent to Use Photographs of Minors in Official Church. Publications of Pohick Church