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Registration 2019
June 9th - June 13th- (6:00pm - 8:30pm) Dinner @ 5:30pm
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* Indicates required question
Students must be registered in order to attend VBS.
(A form must be completed for each child attending individually. Sorry for the inconvenience.)
Student's First Name:
*
Your answer
Student's Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age:
Your answer
Current Grade Level: (grade you just completed)
*
Pre-K
Kindergarden
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th grade
Special Education/Special Needs
Required
Special Education/Special Needs (Additional Info)
Your answer
Address: (Street address only)
*
Your answer
City, State, Zip Code: (Ex. Lebanon, TN, 37090)
Your answer
Parent(s) or Legal Guardian Names
*
Your answer
Cell/Work Number - Ex. (615) 449-6647 - Cell
*
Your answer
Emergency Contact: (Ex. Aunt, Uncle, Best Friend etc.) Jane Doe - Aunt
*
Your answer
Emergency Contact Number: (Ex. 615-449-6647 - Aunt)
*
Your answer
During VBS, I permit my child to be picked up by: (Ex. Jane Doe - Mother, John Doe - Grandfather etc.)
*
Your answer
List any food allergies or health conditions.
*
Your answer
E-Mail
*
Your answer
I permit my child's name and food allergies to be posted for VBS staff members to see.
*
Yes
No
N/A
I permit VBS staff to administer bug repellent and or sunscreen to my child during outdoor activities in the event that either becomes necessary.
*
Yes
No
Pictures of my child may be used in future VBS promotional material/website.
*
Yes
No
My Child has permission to attend and participate in VBS Summer Camp at Rocky Valley Baptist Church.
*
Yes
No
Signature/Date: (Ex. Jane Doe - 5/15/2016)
*
Your answer
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