VBS Enrollment

Vacation Bible School Registry

Please fill out the form below to complete your enrollment in VBS at FBC New Brockton!

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Child's First name

Child's Last name

Birth Date

Age

Grade Completed

Male/Female

Parent/Guardian

Parent/Guardian Phone

Address

E-mail

EMERGENCY CONTACT NAME AND PHONE

IS YOUR CHILD ON DAILY MEDICATION?

IF SO, MEDICINE NAME, DOSAGE AND REASON

SPECIAL NEEDS/ALLERGIES?

PLEASE LIST THE NAMES OF THOSE WHO WILL BE ALLOWED TO PICK UP CHILD (OTHER THAN PARENT)

ARE YOU A MEMBER OF FBC New Brockton?

I give permission for my child's picture/Video to be used in all FBC New Brockton publications. (Photo/Video Release)

MEDICAL, PUBLICITY AND CHILD RELEASE AUTHORIZATION I, the parent and/or legal guardian of the above named minor do hereby appoint FBC New Brockton to act on my behalf in authorizing emergency medical, dental, surgical care and or hospitalization for this child in the event I cannot be reached. I agree to be financially responsible for all treatment. I give permission for my child to be picked up by the persons listed above. (type out name for Signature)

Date (YYYY-MM-DD)

FBC New Brockton

VBS Enrollment

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FBC New Brockton

VBS Enrollment

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FBC New Brockton