Child’s Name: _________________________________  Age: ______

Street address: ___________________________________________

City: ________________________ Phone: _____________________

Parent/Caregiver’s cell phone: _______________________________

Home email: _____________________________________________

Date of Birth: ____________________________________________

School Grade Next Fall: _______________________________

In case of emergency, contact: _______________________________

________________________________________________________

Mother: _________________________________________________

Father: __________________________________________________

Home Church: ____________________________________________

Allergies or medical conditions: ______________________________

Medical Release
In the event of an emergency where medical treatment is required;
I give my permission to the VBS Staff to obtain the services of a
licensed physician. Please attempt to notify me immediately concerning
any such emergency.

Signed: _________________________________ Date: ___________

Lab Crew Number (for church use only): _______________________

PLEASE RETURN FORM WITH $2 DONATION TO THE CHURCH OFFICE