Vacation Bible School Student Registration

Vacation Bible School Student Registration

Historic St Paul AME Church VBS student registration form. Please complete the child, parent/guardian, emergency, health, attendance, permission, and signature details as applicable.
Child Information
Child Full Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Age
Grade Last Completed
School
Home Church
Siblings Attending
Parent/Guardian Information
Parent/Guardian 1 Name

First NameMiddle NameLast Name
Parent/Guardian 1 Relationship
Parent/Guardian 1 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 1 Email
example@example.com
Parent/Guardian 2 Name

First NameMiddle NameLast Name
Parent/Guardian 2 Relationship
Parent/Guardian 2 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Email
example@example.com
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State/ZIP
Emergency and Health Information
Emergency Contact 1 Name
Emergency Contact 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Relationship
Emergency Contact 1 Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Name
Emergency Contact 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Allergies / Medical Conditions
Medications / Health Instructions
Dietary Restrictions / Special Needs
Family Doctor / Clinic
Family Doctor / Clinic Phone
Please enter a valid phone number.Format: (000) 000-0000.
Attendance and Authorized Pick-Up
Days expected to attend
Person normally dropping off
Person normally picking up
Authorized Person 1 Name
Authorized Person 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 1 Relationship
Authorized Person 1 May Pick Up?
Authorized Person 2 Name
Authorized Person 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 2 Relationship
Authorized Person 2 May Pick Up?
Authorized Person 3 Name
Authorized Person 3 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Custody/Safety Restrictions or Persons NOT Authorized
Permissions and Agreements
Photo/Video Permission
Text/Email Updates
Medical Authorization
Participation Agreement
Parent/Guardian Signature
Signature Date

MonthDayYear
Date
Printed Name
Relationship to Child
Staff/Admin Use Only
Notes for VBS Leaders
Date Received

MonthDayYear
Date
Received By
Assigned Group/Class
Check-In Badge/Tag #
Photo Permission Flag
Medical/Allergy Alert Flag
Should be Empty:

Vacation Bible School Student Registration

Child Information

Parent/Guardian Information

Emergency and Health Information

Attendance and Authorized Pick-Up

Permissions and Agreements

Staff/Admin Use Only