Child's Name

First Name

Last Name

Child's Age

Child's Birthdate

YYYY

Child's Grade

Parent/Guardian Name(s)

First Name

Last Name

Parent/Guardian Preferred Phone Number

(###)

###

####

Parent/Guardian Preferred Email Address

Emergency Contact 1 Name

First Name

Last Name

Emergency Contact 1 Phone Number

(###)

###

####

Emergency Contact 2 Name

First Name

Last Name

Emergency Contact 2 Phone Number

(###)

###

####

Doctor's Name

First Name

Last Name

Doctor's Phone Number

(###)

###

####

Allergies/Special Needs

Who may pick up your child at the end of each VBS day?

First Name

Last Name

Relationship

First Name

Last Name

Relationship

I approve my child to attend VBS at Apostolic Faith Tabernacle 1319 E. 17th

Yes.

No.