VBS Registration Form

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Child's Name(Required)

First Last

Grade Entering in September(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email Address(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian's Phone Number(Required)

Child's Allergies/Medical Conditions(Required)

Emergency Contact if Parent/Guardian Cannot Be Reached(Required)

First Last

Emergency Contact Phone Number(Required)

Individuals allowed to pick up child if Parent or Guardian not available(Required)

Permission(Required)

The above named child has my permission to attend the VBS program every day. I also give permission for the above named child’s voice and image to be included in photos/videos for promotional purposes. I promise not to hold Bethel Memorial Baptist Church, its staff, the host or sponsoring church responsible for any injuries or sickness that has occurred at or as a result of this program.

Electronic Signature (Parent/Guardian, please type your name and acknowledge that you are signing electronically below)(Required)

Electronic Signature Acknolwedgement(Required)

I understand that by typing my name in the above form it constitutes an electronic signature and I hereby give my permission with that electronic signature.

I understand that any pictures of me or my child may be used for electronic or paper promotional purposes

Things not to bring

Electronics, Alcohol/ tobacco/illegal substances, Jewelry, Knives/weapons of any kind, Money