2023 Immanuel VBS Participant Registration Form

Ages 3-12

Tuesday, June 13- Thursday, June 15

6:00-8:15 pm

UNLESS OTHERWISE INSTRUCTED BELOW, ONLY THE CHILD’S PARENT/GUARDIAN (LISTED IN THE NEXT SECTION) MAY PICK UP THIS CHILD AFTER VACATION BIBLE SCHOOL EACH DAY.

Medical Emergency Disclaimer

If your child has a medical emergency, and we are unable to get in touch with any or all emergency contacts, we reserve the right to contact emergency services on behalf of you and your child.

Child's full name

Child's age

Last grade completed

Street address (incl. City, State, Zip)

Date of birth

Is this child baptized?

If child is baptized, date of baptism

Does your child have any allergies or medical conditions? Please include details below (NOTE: in case of an allergic reaction or medical emergency, we will use the Emergency Contact info listed at the bottom of this form)

Parent/Guardian's full name

Relationship to child

Street Address (incl. City, State, Zip)

Daytime Phone

Home Church (Name, City)

Pastor's Name

EMERGENCY CONTACT NAME(S)

EMERGENCY CONTACT NUMBER(S)

DIGITAL SIGNATURE (I understand entering my first name and last name below constitutes the equivalent of my written signature.)