VBS 29 JUNE TO 3 JULY LOCATION: 1402 12th ST. AUGUSTA, GA 30906

PARENT(S) NAME

Phone

Address

This address will receive a confirmation email

CHILD NAME

AGE

DATE OF BIRTH

GRADE COMPLETED

EMERGENCY CONTACT

Adult Name

Phone

Address

RELATIONSHIP TO CHILD

CHILD'S MEDICAL PROFILE

ALLERGIES

FOOD MEDICINE SEASONAL

LIST ALLERGIES

FAMILY DOCTOR NAME/NUMBER

SIBLINGS ATTENDING VBS

NAME SIBLING 1

NAME SIBLING 2

NAME SIBLING 3

AUTHORIZED PICK UP PERSON

Adult Name

Phone

RELATIONSHIP TO CHILD

Vacation Bible School (VBS) leaders have permission to photograph/film the minor(s) designated above for any lawful purpose associated with this VBS program. Check box below

Thank You for giving us the opportunity to teach your child(ren) more about God and give them the opportunity to have fun while they learn!

Permission to photograph/film

Yes No

Signature

Date:

Description

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VBS 29 JUNE TO 3 JULY LOCATION: 1402 12th ST. AUGUSTA, GA 30906

Description

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