Vacation Bible School Registration Form

STUDENT INFORMATION
Vacation Bible School Registration Form

Shiloh Missionary Baptist Church
Institution Name
Name

First NameLast Name
M.I.
Gender
Grade completed by
Have you previously attended VBS?
Home Church (if any)
If yes, what year?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Siblings Enrolled in VBS
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACTS
Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.
Primary Guardian

First NameLast Name
Relationship to child
Phone Number
Format: (000) 000-0000.
Alternate Guardian #1

First NameLast Name
Relationship to child
Phone Number
Format: (000) 000-0000.
Alternate Guardian #2

First NameLast Name
Relationship to child
Phone Number
Format: (000) 000-0000.
Medical Information
Please list all allergies -- or type "none" if there are none
Does your child carry an epi-pen? (please note: if yes, it is the responsibilty of the child's guardian to ensure the child has the epi-pen at every drop off and pick up)
Please list all medical concerns -- or type "none" if there are none
Additional Information
Please list the names of any other children (friends or family) that you would like placed in the same class as this child
VBS photos/videos are taken for promotional purposes related to Shiloh Missionary Bapist Church and Vacation Bible School. These pictures appear in various media outlets such as The News and our facebook page and webpage. Do you allow your child to be included in these photos/videos?
By submitting this form, I ackowledge I have read and understand the above information.
Signature
Should be Empty:

Vacation Bible School Registration Form

Medical Information

Additional Information