VBS 2017 Registration form

General Information
Child's Name *
Child's Name
Parent/Guardian's Name *
Parent/Guardian's Name
Home Address *
Home Address
Primary Phone Number *
Primary Phone Number
Age Information
Birth Date *
Birth Date
Please list any medical information (including allergies) or other information we need to know about.
Emergency Contact *
Emergency Contact
Emergency Contact Number *
Emergency Contact Number
Dismissal Information
Please use commas to separate names.
Other Information
May we have permission to photograph/video your child? *
May we have permission to photograph/video your child for the purpose of promotion? *