| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Preferred Name for Name Tag: |
__________________________________ |
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| Primary Phone: |
(______)______-________ |
| Work Phone: |
(______)______-________ |
| Cell Phone: |
(______)______-________ |
| Email: |
__________________________________ |
| Gender: |
Male Female (circle one) |
| *Birthday: |
__________________________________ |
| *Last Grade Completed: |
__________________________________ |
| Allergies, Medical, & Special Needs: |
|
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| *Authorized Pickup #1: |
__________________________________ |
| Authorized Pickup #2: |
__________________________________ |
| Authorized Pickup #3: |
__________________________________ |
| Authorized Pickup #4: |
__________________________________ |
| *By enrolling in VBS, I understand that the Bethel media team might take picture or video of my child for in church recap and promotional uses. Please email hilary@bbcnorman.com if you need to opt out!: |
Agree (circle one) |
| Are you a member of this church?: |
Yes No (circle one) |
| Guest of: |
__________________________________ |
| Do you attend Church?: |
Yes No (circle one) |
| If so, where?: |
__________________________________ |
| Comments: |
|
