Child's Name:  *

Gender Required  *

Grade Completed:  *

Birthday:  *

Age:  *

Parent's Names:  *

Parent's Email Address:  *

Address:  *

City:  *

State/Zip Code:  *

Home Phone:  *

Alternate Phone:  *

Emergency Contact Person:  *

Relationship to Child:  *

Contact Phone Number:  *

Food Allergies: YesNo

List if Yes:

Medical Concerns: YesNo

List if Yes:

Family Doctor  *

Phone Number:  *

Siblings Attending VBS: (names and ages)  *

How did you hear about us?:  *

People who may pick up the Child/Children:  *

T-Shirt Size: Child SChild MChild LAdult SAdult MAdult L

VBS leaders have permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with this VBS program: YesNo

* indicates a required field