Register for VBS

Family Information

Address

Primary Phone

Alternate Phone

Relationship to Student Father Mother Grandfather Grandmother Great-grandfather Great-grandmother Brother Sister Uncle Aunt Guardian Foster Parent Granduncle Grandaunt Other

Phone Number

Permission to pick up my child(ren):

Names of adults I authorize to pick up my child from VBS, other than parent/guardian(s) listed above: (Photo ID will be required if a person is not known to VBS s

Photo Release

Please click one option. Photo Release: I give consent to Mt. Ephraim Baptist Church to use my child(ren)’s photograph, and/or artwork for public relations purposes (bulletin board, website, brochures). Names will not be used.

Medical Release

Medical Release: In the event of a emergency I authorize personnel of Mt Ephraim Baptist church to render or seek necessary medical care on behalf of my minor child including emergency medical transportation and treatment at an emergency medical facility. In the event that a medical emergency occurs, personnel at Mt Ephraim Baptist Church will notify the listed parent (s) and/or guardian (s) listed as soon as possible. Submission electronically of the registration form for the child(ren) indicates your agreement with the above statement. Please read and click the checkbox.

Student Information

Gender

Birth Date

Grade Level

Age Group

Food Allergies

Details

Medical Concerns

Details

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