| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Preferred Name for Name Tag: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Birthday: |
__________________________________ |
| *Last Grade Completed: |
__________________________________ |
| Allergies, Medical, & Special Needs: |
|
| Learning Needs: |
|
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| *Email: |
__________________________________ |
| *Cell Phone: |
(______)______-________ |
| Home Phone: |
(______)______-________ |
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| *Authorized Pickup #1: |
__________________________________ |
| Authorized Pickup #2: |
__________________________________ |
| Guest of: |
__________________________________ |
| Do you attend church?: |
Yes
No (circle one) |
| If so, where?: |
__________________________________ |
| Do you own a Bible?: |
Yes
No (circle one) |
| If no, would you like a Bible?: |
Yes
No (circle one) |
| *Meal before VBS: |
Yes
No (circle one) |
| If yes, how many will be eating?: |
|
| *Photograph for Crafts: |
Yes
No (circle one) |
| *Photograph for Church Publications: |
Yes
No (circle one) |
| Comments: |
|
