Company Parent's Name * (parent or guardian) Email * Home Phone * (enter mobile if no home phone) Mobile Phone Street Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Emergency Contact (other than parent) Emergency Contact Phone Church You Regularly Attend How did you hear about VBS? Number of Children You'd Like to Register * OneTwoThreeFourFiveSix Child 1 * Age * 4 5 6 7 8 9 10 11 12 13 14 Grade * 1st 2nd 3rd 4th 5th 6th 7th 8th Birthday Known Conditions Allergies Additional Information Medical Release The VBS Staff will make every attempt to reach the parent or legal guardian listed, or the emergency contact given on your registration. Doctor's Name Doctor's Phone In case of emergency, I hereby give my permission to the physician selected by the RPC VBS Staff to secure proper treatment and/or hospitalization for child(ren). Your Typed Name Will Act As Your Signature *
