VBS Registration

Child's Name

First Name

Last Name

Grade Entering in Fall

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Emergency Contacts

Please indicate any specific concerns about your child’s allergies, medical concerns, cognitive disabilities, history of trauma or abuse, behavioral diagnosis, etc… including if they will carry epi-pens or inhalers:

Dismissal Information: Name the person(s) who may pick up this child from VBS each day

Yes, I give permission for my child to be photographed or videotaped as part of Galilee Baptist Church activities. I recognize that his or her image may appear in a church or community publication.

No, I do not give permission for my child to be photographed or videotaped as part of Galilee Baptist Church activities.

Date

YYYY