This adventure is for all children 5 years old by September 1 through just completed 6th grade. |
*Participant's First Name: |
__________________________________ |
*Participant's Last Name: |
__________________________________ |
*Parent/Guardian Name: |
__________________________________ |
*Address: |
__________________________________ |
*City: |
__________________________________ |
*State: |
__________________________________ |
*Zip: |
__________________________________ |
*Home Phone: |
(______)______-________ |
Cell Phone: |
(______)______-________ |
*Email: |
__________________________________ |
*Birthday: |
__________________________________ |
*Gender: |
Male Female (circle one) |
*Last Grade Completed: |
__________________________________ |
Allergies, Medical, & Special Needs: |
|
Those who have completed 4th grade and older MUST pick an Activity Track. Five year olds through completed 3rd grade DO NOT select an activity. |
Activity Track: |
__________________________________ |
*Emergency Contact Name (1): |
__________________________________ |
*Emergency Contact Phone (1): |
(______)______-________ |
Emergency Contact Name (2): |
__________________________________ |
Emergency Contact Phone (2): |
(______)______-________ |
A Picture ID is Required for Pick Up |
*Authorized Pickup #1: |
__________________________________ |
Authorized Pickup #2: |
__________________________________ |
Authorized Pickup #3: |
__________________________________ |
Authorized Pickup #4: |
__________________________________ |
*Do you attend Hibernia Baptist?: |
Yes No (circle one) |
*Do you attend a different church?: |
Yes No (circle one) |
If so, where?: |
__________________________________ |
*How did you hear about VBX at Hibernia?: |
__________________________________ |
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: |
|