VBS Registration

Child's Information
Please list all children you are registering for VBS*
You can list more children by clicking the plus sign to the right.
First Name Last Name Birthday (MM/DD/YYYY) Grade 2022/2023 School Year

Parent's Information
Parent's Name*
First Last
Please list all other adults living with the child(ren) and their relationship with them*
Parent's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone Number*
Secondary Phone Number
Parent's Email*

Medical and Security Information
Please list all adults who will pick up your child(ren) from VBS*
They will need the ID claim tag issued at drop-off
Do any of the children coming to VBS have any allergies?*
Please list each child and their allergy*
What should we do in the event of a reaction?*
Insurance Company Name*
Insurance Policy Number*
Emergency Contact Information
An emergency contact must be an individual other than a parent or guardian. This person will be contacted in case of an emergency when the parent's or guardians cannot be reached
Emergency Contact Name*
First Last
Relationship to Child(ren)*
Contact Number*

Signature and Release
I (Parent/Guardian) do hereby give my permission for my child(ren) to attend Vacation Bible School at Duplain Church of Christ. Furthermore, in the event of a medical emergency, I authorize my child(ren) to receive emergency medical care. In addition, I will not hold Duplain Church of Christ of St. Johns, MI, or any employee or representative thereof, responsible for any expense, claims, or liability arising from an injury to my child. Furthermore, I authorize the use of any media containing my child for the sole purpose of church promotion with the understanding that my child's personal information including name will not be used. I also agree to sign this form by way of electronic submission below.
Signature*
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

First Name	Last Name	Birthday (MM/DD/YYYY)	Grade 2022/2023 School Year

Child's Information