Student information

Child's Name *

Child's Name

First Name

Last Name

Parent/ Guardian Name *

Parent/ Guardian Name

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Email Address *

Age information

Birthdate *

Birthdate

YYYY

Last Grade Completed/ Age *

Medical Information

Medical or other information we need to know. Please include food allergies. *

Emergency Contacts

Other than listed above

Emergency Contact #1 *

Emergency Contact #1

First Name

Last Name

Contact #1 Phone Number *

Contact #1 Phone Number

(###)

###

####

Emergency Contact #2

First Name

Last Name

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.)

Approved to pick up *

Approved to pick up

other information

Does your child attend Sunday School/ Church? If so, where? *

If your child is visiting our church, who is he/she a guest of?

May we use photographs of your child for promotional purposes? *

Yes

VBS 2017 Reg Form

Calvary Chapel Shreveport

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