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Child's' Name:
Childs Age: Childs Grade in Fall 2023:
Parents Names:
Address:
City: Zip: E-mail:
Phone: Work: Cell:
Emergency Contact Person:
Emergency Contacts Phone: Emergency Contacts Cell:
Church membership at:
Please list any medical/health conditions or allergies that we should be aware of:
Video/Photo & Activities Release: I hereby grant the VBS leaders permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with this VBS program. I also grant permission for my child to participate in the fitness activities each night.
Signature of Parent or Guardian: Date:
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