Vacation Bible School - Erieside Church

CHILD INFORMATION (Register up to 3 below)

Child #1 Name*

First Last

Gender*

Male
Female

Date of Birth*

DD

MM

YYYY

Last school grade completed (Pre-K through 5th)*

Allergies & Medical/Chronic Issues (if any)

Child #2 Name

First Last

Gender

Male
Female

Date of Birth

DD

MM

YYYY

Last school grade completed (Pre-K through 5th)

Allergies & Medical/Chronic Issues (if any)

Child #3 Name

First Last

Gender

Male
Female

Date of Birth

DD

MM

YYYY

Last school grade completed (Pre-K through 5th)

Allergies & Medical/Chronic Issues (if any)

PARENT INFORMATION

Name of Parent(s)/Legal Guardian:*

Address:*

Street Address Address Line 2 City State ZIP Code

Parent/Caregiver's Contact #:*

Email Address*

In Case of Emergency Contact:*

Phone #:*

Relationship to Child*

Do you have a friend you'd like to be placed with? Write his/her name here:

People Authorized to Pick-Up Your Child (if you cannot):*

Do NOT leave blank ~ write "NONE" if there is to be no one else.

Will you/your child be joining us for a kid-friendly diner at 5:30?*

YES
NO
SOME DAYS

Who will be joining us?*

Child(ren) Only
Child(ren) & Parent

Other Comments & Information

Photography Consent*

YES

I grant Erieside Church and/or the VBS Leaders permission to photograph the minor(s) designated above in any manner for any lawful purpose associated with the VBS program

Electronic Signature (type your full name in space below):*

I agree that my electronic signature is the legally binding equivalent to my handwritten signature, and has the same validity and meaning as my handwritten signature.

JOIN US FOR VBS 2020 at ERIESIDE

VBS 2021 REGISTRATION

CHILD INFORMATION (Register up to 3 below)

PARENT INFORMATION