Vacation Bible School Registration
Walker Pentecostal Church | 9969 Florida Blvd. | Erica Rouse 601.337.3159
Tuesday, July 28th - Thursday, July 30th- 6PM | Friday, July 31st- 7PM
Ages: 4 years - 12 years
Child Information
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age:
*
Gender:
*
Male
Female
Parent / Guardian Information
*
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact Information
If possible, this should be someone other than the parent.
*
First Name
Last Name
Relationship to Child:
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical and Allergy Information
Does your child have any allergies (food, medication)?
*
Are there any medical conditions we should be aware of?
*
Does your child carry an EpiPen or any medication?
*
Authorized Pick-Up
Children will only be released to adults listed in this section unless written permission is provided.
Name
First Name
Last Name
Relationship to Child:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Relationship to Child:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Relationship to Child:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Van Transportation
For questions, please contact: Heidi Fisher 📞 225.610.2241
Will your child need transportation to and/or from Vacation Bible School? Please check the box below and our transportation coordinator will contact you with pickup details.
*
Yes
No
Permission and Release:
Signature
*
I am the parent/legal guardian of the child listed above. By checking the box below, I give permission for my child to attend Vacation Bible School at Walker Pentecostal Church. In case of emergency, I authorize VBS staff/volunteers to seek necessary medical care for my child if I cannot be reached. I also give permission for my child to be photographed or recorded during VBS activities for church use, including social media, website, or printed promotions. I understand and agree to follow all child pickup and checkout procedures for the safety of all children.
*
I agree
Continue
Continue
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