2018 VBS Registration | Old Camp Church

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Sex*

Grade this fall:*

Birthdate:*

Child lives with: Please check below*

Mother's Name

First Last

Mother's Phone

Father's Name

First Last

Father's Phone

The following person(s) MAY pick my child up:*

The following person(s) MAY NOT pick my child up:*

Child's Doctor*

Doctor's Phone Number*

Please list any medical problems or regular medications that your child may be taking:*

Allergies:

List 2 emergency contact people, who, in the case of an emergency and you cannot be reached, would be able to take responsibility for your child:*

Name, Phone number and relationship to your child

I give my permission for my child/children to have their pictures posted on Facebook or social media. Please check Y/N*