Student information
Child's Name *
Child's Name
Parent/ Guardian Name *
Parent/ Guardian Name
Address *
Address
Phone *
Phone
Age information
Birthdate *
Birthdate
Medical Information
Emergency Contacts
Other than listed above
Emergency Contact #1 *
Emergency Contact #1
Contact #1 Phone Number *
Contact #1 Phone Number
Emergency Contact #2
Emergency Contact #2
Contact #2 Phone Number
Contact #2 Phone Number
Dismissal Information
Who may pick up your child at the end of each VBS day? (Please list anyone that might be a possibility, your child will not be released to anyone not listed.)
other information
May we use photographs of your child for promotional purposes? *