Members

Vacation Bible School Application

9:00 a.m. - 5:00 p.m. (Before and After Care Available)

Child

Child's Name

Age

Gender

Grade

MOTHER/GUARDIAN INFORMATION

Mother/Guardian

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email

FATHER/GUARDIAN INFORMATION

Father/Guardian

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email

EMERGENCY CONTACT INFORMATION

Name

Relationship to child

Home Phone

Home Email

Cell Phone

Additional persons who may pick up your child

MEDICAL INFORMATION

Name of Physician

Phone

Health Insurance Provider

Health Insurance ID

Does your child have a medical condition that would limit his/her participation?

List medical condition(s)

List medical limitations

Allergies

Note: In the event of a medical emergency, we will attempt to contact you and your physician. However, we reserve the right to seek immediate medical attention. NO MEDICATION WILL BE DISTRIBUTED BY VBS STAFF.

Does your child have any behavioral issues or need special attention? If so, please describe

Other Information

Does your child play a musical instrument?

Which instrument does he/she play?

VOLUNTEERING

I am available to volunteer

Date

Amount Enclosed

Note that a background check is required for those working directly with the children.