Vacation Bible School Registration Form

Child's Name

Date of Birth

Age as of June 1, 2019

Grade in Fall 2019

School for Fall 2019

Church Affiliation

Has your child attended VBS at St. Mary's previously?

Yes No

T-Shirt Size

Please list any medical concerns, conditions, or prescriptions. If none, please state "none".

Please list any food allergies. If none, please state "none".

Is there anything you would like to share about your child that will help us serve your family better? Any other comments or concerns? If none, please state "none".

Parent/Guardian's Name

Parent/Guardian's Phone

Parent/Guardian's Email

This address will receive a confirmation email

Emergency Contact's Name

What is the Emergency Contact's Relationship to Child?

Emergency Contact's Phone

Name(s) and contact information for person(s) authorized to pick up your camper

Are there any activities in which your child should not participate? If none, please state "none".

I authorize leaders of St. Mary's Episcopal Church to request medical care for my child in the event of an emergency:

Yes No

I grant permission for St. Mary's Episcopal Church to record media of my child and use said media for non-commercial purposes. This media may be in the form of a photograph, film, audio, video, digital, or other electronic format, and may be used on the St. Mary's website or Facebook page. Published documents will not include child's full name or personal information.

Yes No

Payment $25.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Please fill out this form and click submit.

Vacation Bible School Registration Form

Description

Please Fix the Following