VBS 2021

If you or your child would like to participate in this event as a Participant, please complete the following form.

(If you are under 18, please have your parent or guardian complete the form.)
Personal Information

*Participant's First Name:
*Participant's Last Name:
*Preferred Name for Name Tag:
*Gender:
*Parent/Guardian Name:
*Address:
*City:
*State:
*Zip:
Primary Phone:
(555-555-5555)
Work Phone:
(555-555-5555)
Cell Phone:
(555-555-5555)
*Email:
*Birthday:
(MM/DD/YYYY)
*Grade Completed:
(Please select the grade your child will have completed by June 7, 2021.)
If PreK, will this child be 5 before Aug. 15?:
Allergies, Medical, & Special Needs:
(Leave Blank if None)
*Medical Release Statement:
*Emergency Contact Name (1):
*Emergency Contact Phone (1):
(555-555-5555)
Emergency Contact Name (2):
Emergency Contact Phone (2):
(555-555-5555)
*Authorized Pickup #1:
Authorized Pickup #2:
Authorized Pickup #3:
Authorized Pickup #4:
Do you attend Church?
If so, where?
May we have permission to photograph your child?
May we have permission to use your child's photograph in church publications?
Comments: