VBS Registration

VBS 2018 Registration Form

* Indicates required field

Parent/Guardian Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Child 1: Name *

First

Last

Child 1: Date of Birth *

Child 1: Please list medical conditions and/or allergies below. *

Child 2: Name *

First

Last

Child 2: Date of Birth *

Child 2: Please list medical conditions and/or allergies below. *

Child 3: Name *

First

Last

Child 3: Date of Birth *

Child 3: Please list medical conditions and/or allergies below. *

Child 4: Name *

First

Last

Child 4: Date of Birth *

Child 4: Please list medical conditions and/or allergies below. *

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Secondary Emergency Contact Name *

First

Last

Secondary Emergency Contact Phone Number *

Attendance - please check off the days your child(ren) will be attending *

August 7 August 8 August 9 August 10

Social Media Permission: Can we share images of your child on Facebook and our website to let everyone see how much fun it is? *

Yes No

Can we contact you for VBS related communications via email?

Email *

Submit