Parent's Name:

Street Address:

City: State: Zip:

Phone Number: Cell Number:

Email Address:

Emergency contact number:

Emergency contact relationship:

Name of person to pick up child(ren):

Pick-up person’s relationship:

Name of home church, if any:

 Child's Name:

• Grade child will be entering in fall:
• Allergies or other medical conditions. Please be specific of food allergies:

Child's Name:

• Grade child will be entering in fall:
• Allergies or other medical conditions. Please be specific of food allergies:

Child's Name:

• Grade child will be entering in fall:
• Allergies or other medical conditions. Please be specific of food allergies:

May we alert the child's crew leader and snack staff of this allergy?

Please Note!  Our churches participate in the Safe Sanctuary Program.  All of our volunteers meet the requirements of our individual church policies including background and reference checks.  We acknowledge each others’ policies and look forward to another great year of VBS together!