| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Birthday: |
__________________________________ |
| *Age or Grade just completed: |
__________________________________ |
| Allergies, Medical, & Special Needs: |
|
| Use comments to enter info such as which class you would like your child placed in, or if you want them in the same class as another child. |
| Comments: |
|
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| Enter phone numbers in the order you want us to call should we need to contact you. |
| *Phone 1: |
(______)______-________ |
| Phone 2: |
(______)______-________ |
| Phone 3: |
(______)______-________ |
| Phone 4: |
(______)______-________ |
| Email: |
__________________________________ |
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| Authorized pickup other than parent guardian: |
|
| Church you attend: |
__________________________________ |
| May we have permission to photograph your child?: |
Yes No (circle one) |
| May we have permission to use your child's photograph in church publications?: |
Yes No (circle one) |
| How did you hear about Flowood VBS?: |
__________________________________ |
