Example - Clone of VBS Registration

Parent's Name *

Parent First Name Parent Last Name

E-mail

Home Phone

Area Code Phone Number

Cell Phone

Area Code Phone Number

Address *

Street Address

City	State / Province
Postal / Zip Code	Country

Emergency Contact during VBS hours *

First Name Last Name

Emergency Phone Number *

Area Code Phone Number

Number of Kids you are Registering

Child 1

First Name Last Name

Child 1 M/F

Male Female

Child 1 DOB

Month Day Year

Child 1 Age group/Grade level just complete 2012-2013

Child 2

First Name Last Name

Child 2 M/F

Male Female

Child 2 DOB

Month Day Year

Child 2 Age group/Grade level just completed 2012-13

Child 3

First Name Last Name

Child 3 M/F

Male Female

Child 3 DOB

Month Day Year

Child 3 Age group/Grade level just completed 2012-13

Child 4

First Name Last Name

Child 4 M/F

Male Female

Child 4 DOB

Month Day Year

Child 4 Age group/Grade level just completed 2012-13

Child 5

First Name Last Name

Child 5 M/F

Male Female

Child 5 DOB

Month Day Year

Child 5 Age group/Grade level just completed 2012-13

Child 6

First Name Last Name

Child 6 M/f

Male Female

Child 6 DOB

Month Day Year

Child 6 Age group/Grade level just completed

*NOTE* The website we use for forms currently has a glitch and will not show the proper amount of fields for Multiple Children's Names. If you would like to register multiple kids at once, fill out the remaining names in the box below by typing in the Name, Gender, Date of Birth, and Age Group/Grade Level they just completed for the 2012-2013 School year.

Register Information for Multiple kids

Are there any child custody concerns that we need to be aware of where an unauthorized individual may try to retrieve your child from VBS?

Yes (If yes, we will contact you for more information) No

Does your child have special needs to where they'll need one-on-one assistance during the week?

Yes (If yes, we will contact you for more information) No

Snacks are provided each day, please obtain a menu and/or provide your own snack if food allergy is severe. Please list any allergies, medical concerns or special needs during VBS hours.

Medical Information

Medical Release Statement:

In case of a medical emergency, I understand every reasonable effort will be made to contact me. In the event that I cannot be reached through reasonable efforts, I hereby give my permission to the physician selected by the VBS Director to secure proper medical treatment including hospitalization. I understand that my personal insurance carrier will be the primary insurer and that Cole Community Church will be the secondary coverage. As the parent/guardian, I further agree that I will not hold Cole Community Church, nor any ministry volunteers or employees, responsible for any accident or injury.

Parent/Guardian Signature

Clear

Home Church

I would like more information about your church We will be attending the BBQ Potluck on Friday Night, June 28 at 6:00 p.m.

Number Attending

To help offset costs, there is a $5.00 suggested donation per child with a $15.00 maximum charge. No one will be excluded if unable to donate.

Amount of Donation

USD VBS Donation