Berwick/Nescopeck Community VBS Registration Form

Berwick/Nescopeck Community VBS Registration Form

(One per child)
Child's Name

First NameLast Name
Child's Age
Birth Date

MonthDayYear
School Grade Entering
Name of Parents/Guardians

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Parent/Guardian's Cell Phone Number

Area CodePhone Number
Home Email Address
Home Church
ALLERGIES OR OTHER MEDICAL CONDITIONS
IN CASE OF EMERGENCY, CONTACT:

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child
OTHER THAN PARENT, in case of EMERGENCY, CONTACT:

First NameLast Name
Phone Number

Area CodePhone Number
NAME OF THOSE WHO MAY PICK UP CHILD:
Permission for child to be photographed and/or videotaped?

YesNo
Permission for child's photo/video to be used in newspaper or church newsletter?

YesNo
PARENT/GUARDIAN SIGNATURE

Clear
Date
Should be Empty: