Learner Registration

Learner Registration

To register your child as a Learner in our 2013 VBS please complete the following form. You must complete a separate registration form for each child that you will be bringing to VBS. All Learners under 18 years of age must have their parent/guardian complete this form. Thank you!

Learner's First Name: Learner's Last Name:

Learner's Birthday (mm/dd/yyyy):

Last Grade Completed (Please choose from this list): (Grade completed as of June 2013)

Gender:

Street Address: City: State: Zip:

Allergies, Medical and Special Needs: (Leave Blank If None)

Parent/Guardian Name:

Home Phone: (555-555-5555) Cell Phone: (555-555-5555)

Email:

Emergency Contact Name #1: Emergency Contact Phone Number #1:

Emergency Contact Name #2: Emergency Contact Phone Number #2:

Authorized Pickup #1: Authorized Pickup #2:

Do you currently attend church, if so, where? How often do you attend?

May we have permission to photograph your child? Yes No

May we have permission to use your child's photograph in church publications/presentations? Yes No

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