VBS 2024

Breaker Rock Beach

July 8 -12

9am – 12pm

Kindergarten – 5th Grade

Child’s Name(Required)

First Last

Parent/Guardian Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Phone(Required)

Emergency Contact Name(Required)

First Last

(Other than listed above)

Emergency Contact Phone(Required)

Birth Date(Required)

Last Grade Completed in School?(Required)

Medical Information/Food Allergies: Medical or Other information we need to know.(Required)

Dismissal Information: Who may pick up your child at the end of each VBS day, If not you?

First Last

Other Information: Does your child attend church? If so, where?

May we have permission to photograph your child?

Yes

May we have permission to use your child’s photograph for the purpose of promotion?

Yes