VBS Student Registration

Student's Name *

First

Last

Grade Completed as of May, 2025 *

Birthday *

Age (3 by September 1, 2024) *

Parents' Names *

Address *

Address Line 1

City

State

Zip Code

Primary Phone *

Alternate Phone *

Email *

Emergency Contact and Phone *

Are there allergies? *

Are there medical concerns? *

If yes, please list all allergies and/or medical concerns...

Family Doctor and Phone *

Preferred Hospital *

Name(s) and age(s) of any siblings attending VBS... *

Church Affiliation / Home Congregation *

People who may pick up the child... *

Photo/Video Waiver *

I grant the VBS leaders permission to photograph my child in any manner or form for any lawful purpose associated with this VBS.