Student's Name *

First

Last

Parent / Family / Guardian Name *

First

Last

Phone

Email *

Street Address

City / State / Zip

Age and Last School Grade Completed

Special Concerns (allergies, special needs, medical concerns, or other) *

Emergency Contacts (Name and Phone) *

Photo Release - Church/VBS has my permission to use my child’s photograph publicly in VBS materials. I understand the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use

• Yes
• No

Submit