SMBC Vacation Bible School 2023
VBS Registration Form must be completed by a Parent/Guardian for each child attending:
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Child's Last Name *
Child's First Name *
Birth Date (Must be 4 years old by 1/1/23) *
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School Grade (Completed in 22-23 School Year) *
Street Address *
City *
State *
Zip Code *
Parent's Cell Phone *
Can this cell phone receive texts? *
Email Address *
Parent/Guardian Name (that is completing this form) *
Emergency Contact (Name and Phone Number) *
Allergies, medical concerns, medications and/or special needs:
Name of church you attend, if any: *
I hereby grant Smith Memorial Baptist Church permission to photograph my child for use on crafts, their website, and/or informational/ promotional purposes (no names or personal information will ever be used). *
Do you agree to the following statement:  I , the parent(s) or guardian(s) of the child registered for SMBC Vacation Bible School June 26-30, 2023, do hereby authorize adult volunteers of Smith Memorial Baptist Church as agent(s) for the parent/guardian, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability Smith Memorial Baptist Church, and any of its ministries or leaders in the event of an accident en route, during and returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence. *
Health Insurance Company Name: *
Insurance Policy Number *
Doctor's Name and Phone Number *
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