| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| *Cell Phone: |
(______)______-________ |
| *Gender: |
Male Female (circle one) |
| Email: |
__________________________________ |
| *Birthday: |
__________________________________ |
| *What is the last grade your child completed?: |
__________________________________ |
| Allergies, Medical, & Special Needs: |
|
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| *Authorized Pickup Person #1: |
__________________________________ |
| Authorized Pickup Person #2: |
__________________________________ |
| *Are you a member of UBC?: |
Yes
No (circle one) |
| Guest of: |
__________________________________ |
| *Do you attend another church other than UBC?: |
Yes
No (circle one) |
| If so, where?: |
__________________________________ |
| *VBS Photo Permission: |
Yes
No (circle one) |
| *T-Shirt Size: |
__________________________________ |
| Comments: |
|
