Child #1 Name:

Child’s nickname:

Child’s gender:

Child’s age:

Date of birth:

Allergies or other medical conditions (i.e. diabetes)

Any special circumstances we should be aware of? (special needs or disabilities, and/or specific considerations) *

Yes

Optional: Please provide any pertinent information at the end of this form if you selected "yes".

Child #2 Name:

Child’s nickname:

Child’s gender:

Child's age:

Date of birth:

Allergies or other medical conditions (i.e. diabetes)

Any special circumstances we should be aware of? (special needs or disabilities, and/or specific considerations) *

Yes

Optional: Please provide any pertinent information at the end of this form if you selected "yes".

Child #3 Name:

Child’s nickname:

Child’s gender:

Child’s age:

Date of birth:

Allergies or other medical conditions (i.e. diabetes)

Any special circumstances we should be aware of? (special needs or disabilities, and/or specific considerations) *

Yes

Optional: Please provide any pertinent information at the end of this form if you selected "yes".

Name of guardian(s)

Street Address

City

State

Zip

Home telephone *

Parent/guardian’s cell phone *

Home email address *

Home church

Custodial arrangement if applicable:

In case of emergency, contact

Phone

Relationship to child

I give permission to call 911 in case of emergency

Parent/guardian signature:

Clear

Please sign by dragging your cursor to write your signature.

Date

Photographs will be taken during VBS. Do you give permission for your child’s photo to be taken? *

Yes

Optional: Special Needs Details

Please fill out this portion only if you selected “yes” to special Needs.

Child’s name

Parent’s name

My child has the following educational label or medical diagnosis:

My child’s primary means of communication is:

Additional information concerning my child’s allergies or food sensitivities:

My child’s favorite activities and interests are:

My child avoids doing or becomes easily frustrated with the following activities:

If my child becomes overwhelmed or frustrated they will respond best to:

My child’s strengths are:

My child needs help with:

What suggestions do you have that may help us create the best possible experience for your child?

What information would you like us to share with other children at VBS that will help them to better know, accept and understand your child?

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