VBS

Child's Name (first & last):

Child's gender:

Child's age:

Date of birth:

Last school grade completed

Name of parent(s)/guardian(s):

Street address:

City:

State:

Zip code:

Parent/Guardian primary phone:

Primary email:

Name of child's home church:

Allergies, medical conditions, special needs?

In case of emergency, contact:

Parent/Guardian listed above

Other (please list next)

Other emergency contact (name/phone/relationship to child):

May we use images and videos of your child for our church promotional purposes? (website, social media, etc.)

Free Text

Crew number or name (for church use only): _____________________________________________________________________________