VBS Registration Form

VBS Registration Form

July 21-25 | 9am-Noon

Please fill out one set of forms per family. You may register up to 4 elementary-aged kids on one form. Should you have any questions, please contact Sarah at sarahs@southrock.cc or Abby at abbyj@southrock.cc.
- Family Name (Last Name of adult or responsible party)*
- E-mail*
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
- ***Please note that the last 4 digits of the above phone number will be your child's safety number, so please make note of this as it will be required at pickup each day.***
- Cell Phone
  
  Area CodePhone Number
- Name of parents or legal guardians*
- Home Church
- Number of children:
- Please list names and ages (grade entering Fall 2023):
- Number of adults
- The "Online Only" option is if you will not be onsite for packet pick up, out of state or otherwise, so you will be sent a link to access PDF downloads of many of the activities shared in the videos throughout the week.
- Child's Name*
  
  First NameLast Name
- Grade entering Fall 2025*
  
  K1st2nd3rd4th5th
- Gender*
  
  MaleFemale
- Age*
- Date of Birth*
  
  MonthDayYear
- Emergency Contact (other than parent/guardian)*
  
  First NameLast Name
- Emergency Phone # (other than parent/guardian) *
  
  Area CodePhone Number
- Does this child have any medical conditions, concerns, or specific medical needs?*
  
  YesNo
- Please note any medical conditions, concerns or other specific medical needs with specifics and severity that you feel VBS leadership should be aware of. (Physical limitations, non-food allergies, emergency medications) Please bring ONLY EMERGENCY Medications when needed & clearly marked with child’s name in Ziploc bag. These medications will be collected at the registration table and given to the nurse.
  Field MUST be filled in if YES was selected above.
- Does this child have any food allergies?*
  
  YesNo
- Please note food allergy specifics and severity (e.g. can be in the presence of the allergen being eaten by someone else, etc). We do provide gluten free options, but MUST be noted below. If their allergy necessitates, please send a safe snack daily.
  Field MUST be filled in if YES was selected above.
- Physicians Name*
  
  First NameLast Name
- Physicians phone*
- Preferred Hospital*
- I would like to register another child for VBS.*
  
  YesNo
- Child's Name
  
  First NameLast Name
- Grade entering Fall 2025
  
  K1st2nd3rd4th5th
- Gender
  
  MaleFemale
- Age
- Date of Birth
  
  MonthDayYear
- Does this child have any medical conditions, concerns, or specific medical needs?
  
  YesNo
- Please note any medical conditions, concerns or other specific medical needs with specifics and severity that you feel VBS leadership should be aware of. (Physical limitations, non-food allergies, emergency medications) Please bring ONLY EMERGENCY Medications when needed clearly marked with child’s name in Ziploc bag. These medications will be collected at the registration table and given to the nurse.
  Field MUST be filled in if YES was selected above.
- Does this child have any food allergies?
  
  YesNo
- Please note food allergy specifics and severity (e.g. can be in the presence of the allergen being eaten by someone else, etc). If their allergy necessitates, please send a safe snack daily:
  Field MUST be filled in if YES was selected above.
- I would like to register another child for VBS:
  
  YesNo
- Child's Name
  
  First NameLast Name
- Grade entering Fall 2025
  
  K1st2nd3rd4th5th
- Gender
  
  MaleFemale
- Age
- Date of Birth
  
  MonthDayYear
- Does this child have any medical conditions, concerns, or specific medical needs?
  
  YesNo
- Please note any medical conditions, concerns or other specific medical needs with specifics and severity that you feel VBS leadership should be aware of. (Physical limitations, non-food allergies, emergency medications) Please bring ONLY EMERGENCY Medications when needed clearly marked with child’s name in Ziploc bag. These medications will be collected at the registration table and given to the nurse.
  Field MUST be filled in if YES was selected above.
- Does this child have any food allergies?
  
  YesNo
- Please note food allergy specifics and severity (e.g. can be in the presence of the allergen being eaten by someone else, etc). If their allergy necessitates, please send a safe snack daily.
  Field MUST be filled in if YES was selected above.
- I would like to register another child for VBS:
  
  YesNo
- Child's Name
  
  First NameLast Name
- Grade entering Fall 2025
  
  K1st2nd3rd4th5th
- Gender
  
  MaleFemale
- Age
- Date of Birth
  
  MonthDayYear
- Does this child have any medical conditions, concerns, or specific medical needs?
  
  YesNo
- Please note any medical conditions, concerns or other specific medical needs with specifics and severity that you feel VBS leadership should be aware of. (Physical limitations, non-food allergies, emergency medications) Please bring ONLY EMERGENCY Medications when needed clearly marked with child’s name in Ziploc bag. These medications will be collected at the registration table and given to the nurse.
  Field MUST be filled in if YES was selected above.
- Does this child have any food allergies?
  
  YesNo
- Please note food allergy specifics and severity (e.g. can be in the presence of the allergen being eaten by someone else, etc). If their allergy necessitates, please send a safe snack daily.
  Field MUST be filled in if YES was selected above.
- _____________________________________________________________________________________
  
  Permissions & Acknowledgements
- Acknowledgement Statements
  
  I give consent to use any photographs of my family taken during VBS 2025 for promotional purposes
- In case of emergency, I understand that every effort will be made to contact the parent/guardian along with the emergency contact. However, if unable to be reached, I hereby give my consent to have my children taken to a hospital emergency room for immediate medical care and/or treatment that is required. Sign below to authorize consent for medical care:*
  
  Clear
- The following are the expectations set in participation in VBS 2025 (please click each item with your child):*
  
  I will listen and participate.I will not leave until a parent/guardian with my safety # picks me up.I will not bring anything that may be considered a weapon: lighter, knife, gun, etc.I will not bring anything that will be a distraction from face to face interactions with attendees and adults: electronic devices, phones, etc.I know if my behavior does not demonstrate positive interactions and is not encouraging to others, I may not be allowed to attend until we meet with parents/guardians.
- By signing my name below, I acknowledge that I have read and discussed these expectations with my child (please sign below using mouse or trackpad):*
  
  Clear
- Date
  
  MonthDayYear
  Date
- By clicking Submit below, I confirm that ALL areas of this form are ready for submission.
- Should be Empty:

July 21-25 | 9am-Noon