Students Name
*
Age
*
Last school grade completed
*
ParentFamilyGuardian Name
*
Address
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Special Needs/Allergies/Medical Information/Other:
*
Home Church if any
Pick Up & Release
Name(s) of person(s) who may pick up this child from VBS
Name
*
Phone
*
Format: (000) 000-0000.
Name
*
Phone
*
Format: (000) 000-0000.
Photo Release
Photo Release Ragersville UCC has my permission to use my childs photograph publicly in VBS materials I understand the images may be used in print publications online publications presentations websites and social media I also understand that no royalty fee or other compensation shall become payable to me by reason of such use
*
Yes
No
Are any family helping with VBS? If yes where:
ParentGuardians signature
*
Offering
This year offering will support Pirate Power Packs & Friends of the Homeless
Print Form
Submit
Should be Empty: