VBS Registration : Berkeley Springs SDA Church Berkeley Springs WV

Preferred Name / Nickname

Gender Male Female

Age

Parent/Guardian Name

Phone Number

Email Address

Emergency Contact Name

Relationship to Child

Emergency Contact Phone Number

Does your child have any allergies?

Yes No

Does your child have any medical conditions or special needs we should be aware of?

Yes No

Is your child taking any medications? (If yes, list and indicate if it needs to be administered during VBS)

Yes No

Doctor's Name and Phone number (optional but helpful)

Who is authorized to pick up your child? (List all approved individuals)

Is there anyone who is NOT allowed to pick up your child?

Do you give permission for photos/videos of your child to be taken and used for church/VBS promotion?

Yes No

Home Church (if any)

How did you hear about our VBS?

Berkeley Springs SDA Church