Kids - VBS Registracion

Learners First Name: *

Learners Last Name: *

Gender

Male
Female

Parent/Guardian Name: *

Address:

City: *

State:

Zip code: *

Home Phone:

Work Phone:

Cell Phone:

E-mail: *

Learners Birthday

Last Grade Completed *

Allergies, Medical & Special Needs:

Emergency Contact 1 Name: *

Emergency Contact 1 Phone: *

Emergency Contact 2 Name:

Emergency Contact 2 Phone:

Authorized Pick Up 1: *

Authorized Pick Up 2:

Authorized Pick Up 3:

Authorized Pick Up 4:

Are You A Member Of Resurrection?

Yes
No

Guest of:

Do You Attend Church?

Yes
No

If so, where?

May We Have Permission To Photograph Your Child?

Yes
No

May We Have Permission To Use Your Childs Photograph In Church Publications?

Yes
No

T-Shirt Size:

Comments: