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:
*Last Grade Completed:
*Parent/Guardian Name:
*Cell Phone:
*Emergency Contact Name (1):
*Emergency Contact Phone (1):
*Authorized Pickup #1:
Authorized Pickup #2:
Authorized Pickup #3:
Allergies, Medical, & Special Needs:
(Leave Blank if None)
*Special Needs:
(Does your child have an IEP or any special accommodations at school that would also be necessary during VBS REMIX?)
(If yes, please provide details)
Do you attend Church?
If so, where?
(Do you have any siblings that are also attending VBS REMIX)
May we have permission to photograph your child?
May we have permission to use your child's photograph in church publications?