Child's Name *

First Name

Last Name

Name of Responsible Adult *

First Name

Last Name

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Phone Contact *

(###)

###

####

Secondary Phone

(###)

###

####

Phone for Doctor *

(###)

###

####

Additional Names of Person who may pick up the child

First Name

Last Name

Additional Names of Person who may pick up the child

First Name

Last Name

My Child may be included in films/photographs of the VBS program for lawful purposes associated with social media, website, etc. *

Yes

No

In case of Emergency, I give permission for my child to receive medical treatment. In case of such emergency, the primary and secondary phone numbers above will be contacted. *

Yes

No