Student Information
Child's Name *
Child's Name
Parent/ Guardian Name *
Parent/ Guardian Name
Address *
Address
Cell Number *
Cell Number
Home Number
Home Number
Work Number
Work Number
Age Information
Birthdate *
Birthdate
Please Select Answer
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? *