Vacation Bible School Registration Form

Vacation Bible School Registration Form
Institution Name
STUDENT INFORMATION
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Grade Level Completed
Have you previously attended VBS?
Home Church (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Siblings Enrolled in VBS
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.
Alternate Emergency Contact

First NameLast Name
Relationship to child
Phone Number
Format: (000) 000-0000.
Medical Information
Please list all allergies -- or type N/A 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 N/A if there are none
Additional Information
Please list the names of any other children (friends or family) that you would like placed in the same class as this child
VBS photos/videos are taken for promotional purposes related to Reflection Ministries and Vacation Bible School. These pictures appear in various media outlets such as our Facebook, instagram, and webpage.
By submitting this form, I ackowledge I have read and understand the above information.
Signature
Should be Empty:

Vacation Bible School Registration Form

Medical Information

Additional Information