VBS 2019! – First Christian Church Pleasanton, KS

By filling out this form, you will be submitting registration of your child to our Vacation Bible School, held at First Christian Church of Pleasanton, from 9:30 a.m. until 11:30 a.m., Monday thru Friday, June 10th – 14th, 2019

Child's Name *

First

Last

Last Grade Completed *

Last Grade Completed

Child's Birth Date *

Child's Birth Date

Child's Age *

Your child's current age

Parent / Legal Guardian Name *

First

Last

Parent or guardian's name

Street Address *

Your home street address

City *

City you live in

State *

Two-letter state designation

Zip *

Zip code + 4

Parent's Home Phone Number *

Parent's Home Phone Number

Mobile Phone

Your Mobile Phone Number.

Parent's Email Address *

Confirm Email

Your email address or the email address of someone who can get messages to you.

Emergency Contact Name *

First

Last

Someone other than yourself whom we may contact in case of emergency

Emergency Contact's Phone Number *

Contact Number for your emergency contact person.

Any Food Allergies Or Medical Concerns? *

Does your child have any food allergies or medical concerns? Select your choice and explain in the next field:

Please List Any Allergies or Medical Concerns:

Please explain any allergies and/or medical concerns your child may have

Family Medical Practitioner *

First

Last

Please name your family's Doctor or other medical professional specific to your child's needs

Family Medical Practitioner's Phone Number *

Your chosen family medical practitioner's phone number

How Many Other Siblings Attending? (Select One) *

Please select the number of this child's siblings that will also be attending. In the paragraph below, please list their names and ages. If "None", select "None"

--Please List Names and Ages, Below:

Please list the names and ages of any other attending siblings, along with their ages, in this space. If "none", leave blank.

Alternative Adult Who May Pick Up The Child:

First

Last

You may choose a responsible adult to be able to pick up your child. However, please contact the office at (913)352-8558 if any early or unscheduled pickup becomes necessary.

Second Alternative Adult Who May Pick Up The Child:

First

Last

You may choose a responsible adult to be able to pick up your child. However, please contact the office at (913)352-8558 if any early or unscheduled pickup becomes necessary.

Will Your Child Need Transportation? *

A limited amount of transportation will be available for those who need it. Please select your reply.

Vacation Bible School (VBS) leaders and teachers may photograph, film and record the above-named minor(s) as well as any adults in attendance for any lawful purpose associated with this VBS program. *

I understand and accept.

Any photographs, filming or recording during VBS will be completely incidental to VBS programming and events, and names will be kept confidential.

Thank you for allowing us the opportunity to teach and give your child(ren) knowledge and experience about God, along with the opportunity to learn and to have FUN at the same time! By typing in your name, below, you acknowledge registering your child(ren) for this VBS program: *

You hereby register this child for VBS.

Today's Date *

Enter today's date as m/d/y

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