*Participant's First Name: |
__________________________________ |
*Participant's Last Name: |
__________________________________ |
*Gender: |
Male Female (circle one) |
*Birthday: |
__________________________________ |
*Age or Grade just completed: |
__________________________________ |
Allergies, Medical, & Special Needs: |
|
Use comments to enter info such as which class you would like your child placed in, or if you want them in the same class as another child. |
Comments: |
|
*Parent/Guardian Name: |
__________________________________ |
*Address: |
__________________________________ |
*City: |
__________________________________ |
*State: |
__________________________________ |
*Zip: |
__________________________________ |
Enter phone numbers in the order you want us to call should we need to contact you. |
*Phone 1: |
(______)______-________ |
Phone 2: |
(______)______-________ |
Phone 3: |
(______)______-________ |
Phone 4: |
(______)______-________ |
Email: |
__________________________________ |
*Emergency Contact Name (1): |
__________________________________ |
*Emergency Contact Phone (1): |
(______)______-________ |
Emergency Contact Name (2): |
__________________________________ |
Emergency Contact Phone (2): |
(______)______-________ |
Authorized pickup other than parent guardian: |
|
Church you attend: |
__________________________________ |
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) |
How did you hear about Flowood VBS?: |
__________________________________ |