VBS Registration

Please fill in as much detail as possible so that we will be able to address any issues or concerns and get in touch with the responsible party for this child, if necessary.

* Required Fields

*Child's full name:
*Grade completed:
Birthday:
*Age:
*Parent Name(s):
*Home Address (street, city, state, zip):
Home Phone:
Alternate Phone (plus owner's name):
*Emergency Contact Person:
*Emergency Contact Relationship:
*Emergency Contact Phone:
Food Allergies (List):
Medical Concerns (Explain):
Family Doctor:
Family Doctor Phone:
Siblings Attending (names and ages):
Church Affiliation:
Church membership at:
People who may pick up the child:
Transportation needed?:	Yes No
By submitting this registration, you give permission to the leaders of this event to photograph/film the minor designated above in any manner or form for any lawful purpose associated with this event.
*Authentication:
*3 + 5 =	Enter the correct answer to the math question.
Please click the Send button only once.

GREEN COVE SPRINGS CHURCH OF CHRIST

Reaching people - sharing Christ

VBS Registration