VBS - Hardinsburg Baptist Church

VBS 2021 June 12-16 5:00-8:00 PM

VBS Registration 2021

* Indicates required field

Parent/Guardian Name *

First

Last

Child Name *

Age of Child *

Grade going into in August 2021 *

Child Name *

Age of Child *

Grade going into in August 2021 *

Child Name *

Age of Child *

Grade going into in August 2021 *

Child Name *

Age of Child *

Grade going into in August 2021 *

Child Name *

Age of Child *

Grade going into in August 2021 *

Child Name *

Age of Child *

Grade going into in August 2021 *

Parent/Guardian *

Telephone Number *

Cell Number *

Email Address *

Mailing Address *

Physical Address (If different from mailing) *

Emergency Contact Name and Number *

Insurance Company and Policy Information *

Special Medical Information: Please list any allergies, medications currently taking, etc. *

Do your child(ren) need bus transportation to and from VBS? (if your child needs transportation we need a signed transportation form) *

Yes No

Click here to access a transportation form if you do not have one completed for your child(ren)

In the event that the above child(ren) are in need of medical care and I am not available for consultation, I do hereby consent to treatment, including diagnostic and surgical procedures, for the participant should a license physician determine necessary *

I consent I DO NOT consent

Occasionally, the Hardinsburg Baptist Church staff or program leaders may videotape or photograph activities in which your child may be participating. These images may be posted on media outlets. We realize that some of you may not want your child's picture published, and we want to respect your decision concerning this matter. Please check the box below.

Permission to Photograph/Video *

Yes, I give permission No, I do NOT give permission

If you have any questions/concerns about VBS please contact Jeanie Tate at 270-756-5230 or jeanie.tate@hardinsburgbc.org

Submit