Vacation Bible School Registration Form

Vacation Bible School Registration Form
Institution Name
STUDENT INFORMATION
Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade completed by
Home Church (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
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
Can pictures be taken of your child as they are participating?
By submitting this form, I ackowledge I have read and understand the above information.

Medical Information