VBS Registration Form "*" indicates required fields Step 1 of 5 20% 3 Years of Age (Potty Trained) to 5th Grade Only. Times- Sun: 3:00p-5:00p | Mon-Thurs: 5:30p-8:00p If you have multiple children attending VBS, we ask that you fill out a form for each child.Child's Name:* First Last Suffix Age*Please enter a number from 3 to 12.Child's Preferred Name Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Does the child have a parent or guardian?* My child has a mother and father. My child has one parent. My Child has a guardian. Mother's Name* First Mother's Personal Cell Number*Work NumberFather's Name* First Father's Personal Cell Number*Work NumberGuardian's Name* First Guardian's Personal Cell Number*Work NumberParent's Name* First Parent's Personal Cell Number*Work NumberEmergency ContactContact 1Contact Name:* First Relationship to Child* Phone Number*Contact 2Contact Name:* First Relationship to Child* Phone Number* Health and InsurancePhysician: First Phone:Insurance Company: Policy Number: Does your child have any restrictions to physical activites?* Yes No Does your child have any allergies (food, drugs, insects, etc...)?* Yes No Please describe your child's physical restrictions:*Please describe your child's allergies:*Describe any other medical conditions or notes here: Does your child attend Christ Lutheran Day School?* Yes No Child's Teacher:* Do you or your child attend church here at Christ Lutheran?* Yes. No, we attend church elsewhere. Home Church:* City:* City Name a special friend/partner your child might like to be with: First Permission to Pick UpThe safety of your child is very important to us. We will not release your child unless it is you, or the person(s) that you choose to list below. If you don't list anyone, you will be the sole pickup person unless changed.List up to 4 other persons that are able to pick up your child.Name:Relationship:Phone Number: Add RemoveUse the "+" on the right to add another row. Emergency ReleaseI will not hold Christ Lutheran Church and their staff responsible for accidents, claims and damages arising from my child’s participation in VBS activities. Additionally, I give Christ Lutheran Church permission to use any photograph/videos of me or my child that is taken during VBS for the promotion of Christ Lutheran Church on our Website, Facebook page, YouTube channel, or during worship services.Consent* I agree to the statement above.*Typing your name below is a binding signatureName:* PrefixDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix Date* MM slash DD slash YYYY Δ
