Child's Gender

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Name of Parent/Guardian *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Valid Phone *

(###)

###

####

Mother's Mobile Phone

(###)

###

####

Father's Mobile Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Name of your Child's Doctor *

First Name

Last Name

Doctor's Phone *

(###)

###

####

During Vacation Bible School, we will be taking pictures of the children so that we can celebrate each day with photo of their activities, and so that those photos can be shared with family members. These photos will also be used for possible in-house publication in the church, the photos will NOT be used for any advertising purposes. As the parent or guardian of the child, do you authorize the photography of your child? *

Yes, I give my permission

No, I do not give my permission