Student's Name 

 

Parent/Guardian Name

  

 

Age Information 

Child's age    Date of Birth  January February March April May June July August September October November December Month    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day    1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year  

 

Grade Completed   Pre-School K 1 2 3 4 5 6 7 8 9 10 11  

 

Medical Information (including any food allergies)

 

Special Instructions for your Pre-Schooler

 

Emergency Contact

Name   Phone Number

Name   Phone Number

 

Name of person(s) whom your child can leave at the end of VBS each evening:

 

Are you a member of a Church?  Yes No   Where?  Rich Pond Baptist Church Other   If other where?

 

If you are visiting our church, who invited you to VBS?   

 

May we have permission to photograph your child?  Yes No  

 

May we have permission to use your child's photograph in church publications for future promotions? Yes No