VBS 2017 Participant Registration

June 11th - 15th @ 6:00pm - 8:30pm | PreK (4 Years Old) thru 5th grade students ONLY!

Please fill out this form and click submit.

Child's Information

Child's Name

*

Child's Gender

*

Please select all that apply.

Male Female

Child's Birthdate

*

Last Grade Completed (2016-2017 School Year)

*

Please select one option.

Pre-K (4 Years Old) Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Child's Allergies, Medical, Special Needs, & Instructions

Parent / Guardian Information

Parent / Guardian Name

*

Address

*

Cell Phone

*

Home Phone

Email

*

This address will receive a confirmation email

Emergency Contact

Contact #1 Name

*

Contact #1 Phone

*

Contact #2 Name

Contact #2 Phone

Authorized Pickup

Authorized Pickup #1

*

Authorized Pickup #2

Authorized Pickup #3

Authorized Pickup #4

Photograph

May we have permission to photograph your child?

*

Please select all that apply.

Yes No

May we have permission to use your child's photograph in our church publications, on our website, and on social media?

*

Please select all that apply.

Yes No

Additional Information

Are you a member of Mt. Harmony Baptist Church?

*

Please select all that apply.

Yes No

If not, how did you hear about us?

Do you attend church?

If so, where do you attend?

Other Comments:

Description

June 11th - 15th @ 6:00pm - 8:30pm

PreK (4 Years Old) thru 5th grade students ONLY!

Please fill out this form and click submit.

Please Fix the Following

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