2017 VBS Preregistration Form

    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)

    Name of Church, if any

    Name of pastor

    Permission to photograph and video your child (required)

    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 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