Child's Name

Parent/Guardian Name(s)

Address

Home Phone

Work Phone

Cell Phone

Email Address

Child's Birthday

Last Grade Completed in School

Medical or other information we need to know

Emergency Contact Name

Emergency Contact #1 Phone Number

Emergency Contact #2 Name

Emergency Contact #2 Phone Number

Who may pick up your child at the end of each VBS day?

Do you regularly attend church? Do you regularly attend church? Yes No

If so, where?

If you are visiting our church, how did you hear about our VBS?

May we have permission to photograph your child for the purpose of promotion? May we have permission to photograph your child for the purpose of promotion? Yes No