VBS Registration

 

 

 

 

Child's Name *

First

Last

Child's Gender *MaleFemale

Child's Age *456789101112

Date of Birth *

(Format: MM/DD/YYYY)

Last School Grade Completed *

Name of Parent/Guardian *

First

Last

Street Address *

City *

State *

ZIP Code *

Phone Number *

(Format: XXX-XXX-XXXX)

Email Address *

Home Church

Allergies or Other Medical Conditions

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

(Format: XXX-XXX-XXXX)

Emergency Contact Relationship to Child *

Photo Release: CCNA/VBS has my permission to use my child's photograph publicly in VBS materials. *

• Yes
• No

Email *

Submit