Child #1 name: *

First Name

Last Name

Child's Gender *

Female

Male

Any special circumstances we should be aware of? (special needs or disabilities, and/or specific considerations). *

No

Yes

Child #2 name: (if applicable)

First Name

Last Name

Child's Gender (if applicable)

Female

Male

Any special circumstances we should be aware of? (special needs or disabilities, and/or specific considerations).

(if applicable)

No

Yes

Child #3 name: (if applicable)

First Name

Last Name

Child's Gender (if applicable)

Female

Male

Any special circumstances we should be aware of? (special needs or disabilities, and/or specific considerations).

(if applicable)

No

Yes

Child's Guardian(s) *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Custodial arrangement if applicable:

First Name

Last Name

I give permission to call 911 in case of emergency

Yes

No

Photographs will be taken during VBS. Do you give permission for your child’s photo to be taken?

Yes

No