VBS Summer Xtreme S.H.I.N.E.
June 8-12 | 8:30 a.m. - 11:45 a.m.
Participant Name
*
First Name
Last Name
Parent/Guardian
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant's Birthday
*
-
Month
-
Day
Year
Date
Participant's Age
*
Grade 2025/2026 School Year
*
Allergies
Please type all allergies
Are you a member of Fairview
Yes
No
Photograph Permission
*
Yes
No
Tractor Ride Permission
*
Yes
No
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How does he/she best communicate needs?
What does he/she like to do?
Are there any aggressive/inappropriate behaviors we should know about?
Are there any triggers for inappropriate behavior?
Does he/she have any dietary, allergies, or environmental issues of which we should be aware?
Does he/she have physical or self-care limitations?
Are there any medical issues such as seizures, diabetes, or medications of which we should be aware?
Would he/she be more successful in a self-contained or inclusion setting when possible?
Is there anything else you would like for us to know?
Submit
Should be Empty: