Child's Name (required)

Child's Birthday (required) - please use this format (mm/dd/yyyy)

Parent(s) Name(s) (required)

Mother's name

Father's name

Home Phone (required) - if no home phone then please put "none" in box

Parent(s) Cell Phone (required) - if no cell then please put "none" in box

Mother's cell

Father's cell

Parent(s) Work Phone(s) (required)

Mother's work phone

Father's work phone

Street Address (required)

City (required)

State (required)

Zip (required)

Parent's Email (required) - if no e-mail then put "none" in the box

In Case of Emergency, Contact (required) - please put first and last name then best phone number for each contact

Who may pick up your child at the end of each day of VBS? (required) - If there will be a regular pick up person then please just list their first and last name (if not a parent or emergency contact, then list phone number after last name). If there will be multiple pick up person then please list the first name, last name, and phone number along with the days they have permission to pick up your child.

Allergies or other medical conditions (required)

Family Doctor - please list first name, last name, and phone number

Age or School Grade Just Completed (required)

infant1yr old2yr old3yr old4yr old5yr oldKind.1st2nd3rd4th5th6th

Name of Church, if any

Name of pastor

Permission to photograph and video your child (required)

yesno I hereby grant permission for Brushy Fork Baptist Church to photograph and/or video my child, [child-name], and use those pictures and/or video for a highlight video and/or slideshow and on their website for informational and promotional purposes.

Any other comments

By placing a check here I certify that I have reviewed the information on this form and it is correct as far as I know