Child Name

First Name

Last Name

Date of Birth

YYYY

Grade Entering in the Fall:

Parent/Guardian

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Preferred number for contact

(###)

###

####

Medical Information

Emergency Contact

Primary

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Secondary Emergency Contact

First Name

Last Name

Secondary Emergency Contact Phone

(###)

###

####

Dismissal Information

How did you hear about Bethel VBS

May we share pictures and/or video of your child on Bethel's web page or any other church publication

Thank you for registering your child for VBS here at Bethel. We look forward to seeing you there!

Bethel Church