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Participant Registration
*Participant's First Name:  __________________________________
*Participant's Last Name:  __________________________________
*Parent/Guardian Name:  __________________________________
*Address:  __________________________________
*City:  __________________________________
*State:  __________________________________
*Zip:  __________________________________
Home Phone:  (______)______-________
Cell Phone:  (______)______-________
Email:  __________________________________
*Birthday:  __________________________________
*Last Grade Completed:  __________________________________
Gender:  Male  Female  (circle one)
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:  __________________________________
Are you a member of this church?:    Yes   No  (circle one)
Guest of:  __________________________________
Do you attend Church?:    Yes   No  (circle one)
If so, where?:  __________________________________
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)
Comments:
My child will need transportation to/from VBS:    Yes   No  (circle one)
* Required