VBS REGISTRATION

VBS REGISTRATION

Grace Community Church - August 17-21
Name of Student

First NameLast Name
Sex
Birth Date
Grade
Parent / Guardian Name

First NameLast Name
Email of Guardian
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Relationship to child
6 digit Provincial Health Insurance Number of Student
9 digit Provincial Health Insurance Number of Student
Does your Child have any allergies and or physical, emotional, mental, behavioral concerns or limitations that our staff should be aware of?

Other
if yes or other, please explain down below
Does your child take any regular medication that we should be aware of?
if yes or other, please explain down below
ONLY FILL THIS OUT IF YOU PLAN ON SENDING YOUR KIDS ON THE BUS
I_________________________________give permission for my child listed above, to be picked up and dropped off by a Grace Community Church representative for VBS
I give permission for future reasonable and safe use of pictures/videos containing your child in the following ways: brochures/promotional material, displays/crafts, Grace Community Church social media/website
Cost of VBS is $40, this covers a t-shirt, meals, etc. How would you like to pay?
Signature
Should be Empty: