VBS REMIX 2025
    Choose one:
     
     
     
    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:
    *Birthday:
    (MM/DD/YYYY)
    *Parent/Guardian Name:
    *Address:
    *City:
    *State:
    *Zip:
    *Last Grade Completed:
    *Cell Phone:
    (555-555-5555)
    *Email:
    *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:
    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?)
    Accomodations:
    (If yes, please provide details)
    Do you attend Church?
    If so, where?
    Siblings:
    (Do you have any siblings that are also attending REMIX?)
    May we have permission to photograph your child?
    May we have permission to use your child's photograph in church publications?
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