VBS Registration 2016

Child's Name*

First Last

Date of birth*

Gender*

Female
Male

Grade Completed

Parent's Name(s)*

Preferred Phone*

Cell Phone

In case of emergency, please provide cell number. Thank you.

Address*

Street Address Address Line 2 City State ZIP Code

Preferred Email*

Church Home (If applicable)

Emergency Contact*

First Last

If you are unable to be reached, who should we call during VBS hours?

Emergency Contact Primary Phone (Cell, Home, etc)*

Provide number which best to reach emergency contact.

Secondary Phone (Cell, home, etc)*

Provide a back up number to reach emergency contact

Names of individuals allowed to pick up child from VBS:*

Food Allergies?*

Yes
None known

Please list allergies:*

Medical Needs*

Yes
None

What medical needs does you child have?

One friend your child would like to be grouped with (If applicable)

Would you like to volunteer?

Yes
No

What would you like to do?*

Be a Center Leader/Helper
Be a Guide

Will you need childcare?

Yes
No

Media Release*

I give permission to Asbury UMC to use any photographs or video taken of my child on their website or any future Asbury publications.
I DO NOT give permission to Asbury UMC to use any photographs or video taken of my child on their website or any future Asbury publications.

Name

This field is for validation purposes and should be left unchanged.

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