VBS Child Registration

* Indicates required field

Child's Name *

First

Last

Gender *

Male Female

Birthdate (mm/dd/yy) *

Grade Completed *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parents/Guardian *

Home Phone Number *

Work Phone Number *

Cell Phone Number *

Email *

Emergency Contact *

Relationship to Child *

Phone Number *

Who can pick up your child? *

Name of Home Church *

Food Allergies *

Yes No

If yes, please list: *

Medical Concerns *

Yes No

If yes, please explain: *

Permission to Use Images and Video

I hereby grant permission for Perry Chapel Baptist Church to record sounds, images, or video of my child while attending this VBS program. I also give permission for Perry Chapel Baptist Church at its sole discretion, to use these sounds, images, or videos in publications (including print, websites, and social media platforms) owned by Perry Chapel Baptist Church in relation to this VBS program. *

Yes No

This is my electronic signature: *

First

Last

Today's Date (mm/dd/yy) *

Submit

2019 VBS Child Registration

Permission to Use Images and Video

We Would Love to Have You Visit Soon!
...Worship Service...Sunday @ 10:40am

Office Hours

Telephone

Address

Email

2019 VBS Child Registration

Permission to Use Images and Video

We Would Love to Have You Visit Soon!...Worship Service...Sunday @ 10:40am

Office Hours

Telephone

Address

Email

We Would Love to Have You Visit Soon!
...Worship Service...Sunday @ 10:40am