VBS 2010 Signup

Child's Name*

First Name Last Name

Grade Completed*

Birth Date*

Month Day Year

Home Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parents' Names*

Home Phone*

- Area Code Phone Number

Alternate Phone

- Area Code Phone Number

Emergency Contact*

First Name Last Name

Relationship to Student*

Phone Number*

- Area Code Phone Number

Alternate Phone

- Area Code Phone Number

Food Allergies*

Yes No

List Allergies

Medical Concerns*

Yes No

List Medical Concerns

Family Doctor

First Name Last Name

Doctor's Phone

- Area Code Phone Number

Siblings Attending VBS

Church Affliation

Church Membership at

People who may pick up the child.*

VBS leaders have permission to photograph/film the minor(s) designated above in any manner or form for lawful purpose associated with this VBS program.

By checking this box I agree to these terms. This check shall serve as my digital signature stating that all information I have provided is correct.*

I Agree