Child #1 (List Oldest to Youngest) *

First Name

Last Name

Child #1 Date of Birth *

MM

DD

YYYY

Child #2

First Name

Last Name

Child #2 Date of Birth

MM

DD

YYYY

Child #3

First Name

Last Name

Child #3 Date of Birth

MM

DD

YYYY

Child #4

First Name

Last Name

Child #4 Date of Birth

MM

DD

YYYY

Child #5

First Name

Last Name

Child #5 Date of Birth

MM

DD

YYYY

Parent/Guardian #1 Name *

First Name

Last Name

Parent/Guardian #1 Phone Number *

(###)

###

####

Parent/Guardian #2 Name

First Name

Last Name

Parent/Guardian #2 Phone Number

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

In the event a parent/guardian cannot be reached, please indicate the next person to contact regarding your child(ren).

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Release and Liability Waiver *

By registering and typing my name below, I give my permission for Faith Community Church to secure medical services for my child(ren) should it be necessary and will not hold Faith Community Church, its directors, its staff, or its volunteers liable for damages. I also understand that photo and/or video images will be taken during VBS, that images will not be sold, and that my child(ren)’s identity will remain anonymous. Therefore I give permission to Faith Community Church to use photo/video images for promotional purposes.

First Name

Last Name