Child's First Name (required)

Child's Last Name (required)

Child Prefers To Be Called (required)

Child's Age (required)

Grade Child Will Enter Next School Year (required)

Parent/Guardian's First Name (required)

Parent/Guardian's Last Name (required)

Parent/Guardian's Phone Number (required)

Parent/Guardian's Home Address (required)

Parent/Guardian's Home City (required)

Parent/Guardian's Home State (required)
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Parent/Guardian's Home Zip Code (required)

Parent/Guardian's Email Address (required)

PLEASE NOTE THAT EACH CHILD'S PARENT/GUARDIAN WILL BE ASKED TO SHOW PHOTO ID EACH DAY TO PICK UP THEIR CHILD FROM VBS

PLEASE LIST AN EMERGENCY CONTACT WHO IS NOT THE CHILD'S PARENT/GUARDIAN

Emergency Contact's First Name (required)

Emergency Contact's Last Name (required)

Emergency Contact's Relationship to Child (required)

Emergency Contact's Phone Number (required)

Does your child have any LIFE THREATENING food or environmental allergies? (required)

YesNo

If yes, please list each one here, include both food & environmental allergies.

Is your child required to carry with them any LIFE SAVING medications or devices? (required)

YesNo

If yes, please list each one here, include both medications & devices.

PLEASE NOTE THAT VBS STAFF CANNOT ADMINISTER ROUTINE MEDICATIONS. PLEASE GIVE YOUR CHILD ANY ROUTINE MEDICATIONS PRIOR TO ARRIVAL AT VBS.

IN THE EVENT OF AN EMERGENCY, VBS STAFF WILL ADMINISTER THE LIFE SAVING MEDICATIONS LISTED HERE. PLEASE ENSURE THAT YOU SEND THEM WITH YOUR CHILD EACH EVENING.

Does your child have any special needs that you would like VBS staff to know?

YesNo

If yes, please comment here.

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