Student First and Last Name, Nickname

Gender

Age and birthdate

Grade entering: 

Must be potty trained and 4 years old May 1, 2024

Home Church (if applicable)

It would be nice if my child was placed in same group as (child’s name)

Parent Name

Address, City, State, Zip

Home number and cell number

Emergency contact and emergency phone

Alternate Pick up name and Alt phone

Release: I give my permission for the VBS staff to administer basic first aid to my child (named above) in the event of an injury.  I understand that the VBS staff will contact emergency services in the event of a significant injury and all expenses for such emergency services will be paid by me.

Initial if agree

Photo release:  I hereby grant the above named churches permission to copyright and use photographs/videos take at VBS of the minor Designated above in any manner or for for any purpose lawful at the time.  I waive any right thatI may have to inspect or approve the finished product or written copy, that may be used in conjunction therewith, or the use to which it may be applied.  

Initial if agree

Permission to Attend: I give permission for my child (named above) to attend the VBS listed above  I understand that the information I give for this registration will only be used by the VBS hosting churches, and that all registration information will be removed from the hosting sites by December 31st of this year.  

initial if agree

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Parent or Guardian Signature                                Date

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