V.B.S.

Registration

We are looking forward to your children joining us for The Great Jungle Journey! Please fill out one registration form per child.

Child Full Name *

First

Middle

Last

Age *

Grade (Going into) *

Shirt Size *

Please list any Allergies (food, drug, other) *

If no allergies, please put N/A.

Special Needs

Please list any special needs or instructions your child may require.

Parent/Guardian Name *

First

Last

I.D. is required to pick up child.

Relation to Child *

Parent/Guardian Name

First

Last

I.D. is required to pick up child.

Relation to Child

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone *

Secondary Phone

Email *

Authorized Pick-Up #1

First

Last

I.D. is required to pick up child.

Relation to Child

Phone

Authorized Pick-Up #2

First

Last

I.D. is required to pick up child.

Relation to Child

Phone

Authorized Pick-Up #3

First

Last

I.D. is required to pick up child.

Relation to Child

Phone

Photo and Video Permission *

My permission is granted for KCBC to photograph or videotape the individuals listed on this form during Vacation Bible School that may be used and posted to social media, website, etc.

To your knowledge, has your child or anyone in your household been exposed to Covid-19 (Coronavirus) in the last 14 days? *

By checking no, you are agreeing that you will not willingly or knowingly put anyone else at risk of contracting Covid-19 (Coronavirus).

By checking the box below, you understand and agree to the statement below. *

I agree

I understand that Kimberlin Creek Baptist Church will keep my child safe, to the best of their abilities. I give permission to treat my child with the appropriate medical treatment in the event that it is required. I agree to not hold Kimberlin Creek Baptist Church, its staff or volunteers liable for any necessary medical treatment or financial responsibility that may occur.

Phone