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VBS Registration

Please enter email address for confirmation upon submission*
First & Last Name (One child per form)
Birth Date
Grade just completed
Please list any Allergies, Medical Conditions, Special Needs
Mother/Father Name
Best phone number(s) to contact during VBS
In my Absence, my child may be released to the following individuals (make sure they have ID that matches the first and last names you list and are 18 or older)
Please use same names for this child as listed on previous child for release in my absence.
Previous Child's Name:
Emergency Contact Name & Phone Number:
In case of an emergency where I cannot be reached, I hereby authorize the VBS staff to administer needed first aid or to seek medical attention for my child*
I give permission for my child's photo to be taken and used for Church purposes
This child will be attending the Thursday Afternoon Activities. (Must have completed Grades 3-6)
My typed name & date is my signature