Student Information Collection Form

Roland Memorial Baptist Church

VBS Student Registration Form
Student Registration Information
Student Name

First NameMiddle NameLast Name
Grade (Beginning Fall 2026)
Allergies or medical conditions
Student Name

First NameMiddle NameLast Name
Grade (Beginning Fall 2026)
Allergies or medical conditions
Student Name

First NameMiddle NameLast Name
Grade (Beginning Fall 2026)
Allergies or medical conditions
Student Name

First NameMiddle NameLast Name
Grade (Beginning Fall 2026)
Allergies or medical conditions
Parent/Guardian Name

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

Emergency Contact Information
Primary Emergency | Contact Name

First NameLast Name
Primary Emergency | Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency | What is your relationship with this person?
Secondary Emergency | Contact Name

First NameLast Name
Secondary Emergency | Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency | What is your relationship with this person?
Pick Up Authorization

Other than the parent/guardian listed above, who may pick up your child(ren) from VBS.
Authorized Person's Name

First NameLast Name
Authorized Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person's Name

First NameLast Name
Authorized Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Van Pick Up Registration
Will your student(s) need a ride to VBS on the church van?
Please note that all students must be potty trained and if a booster seat is required, parent/guardian must provide booster seat each night.

Roland Memorial Baptist Church