Virtual Registration Form
ST JAMES WEST VBS 2023
Registration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Grade Level Completed for 2022/2023 school year
List any Food Allergies or special diets:
Best phone # to reach in case of emergency:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Name 1
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name 2
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Church Name
Authorized person who can pickup the child on dismissal
First Name
Last Name
Authorized person who can pickup the child on dismissal
First Name
Last Name
Agreement
I allow my child to participate in this program or vacation bible school.
I authorize the school, bible study conductor, volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.
I release the school from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Would it be okay if we take photos and videos of the participant during the activity which will be posted in our social media account?
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: