Childs First Name *

Childs Last Name *

Gender

Date of birth *

Grade Completed *

Address

Street Address

City

State

Postal code

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Parent/Guardians Full Name *

Phone

Work Phone Number *

Email *

Emergency Contacts Full Name *

Relationship to Child *

Phone Emergency Contact Phone *

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Please Place My Child With

Home Church *

Food Allergies? *

List Any Food Allergies

Medical Concerns? *

List Any Medical Concerns

I Give Permission to Use Images and Video* - Read Below *

* PERMISSION TO USE IMAGES AND VIDEO - I hereby grant permission for Heritage Baptist Church to record sounds, images, or video of my child while attending Vacation Bible School. I also give permission for Heritage Baptist Church at its sole discretion, to use these sounds, images, or videos in publications (including print, websites, and social media platforms) owned by Heritage Baptist Church.

Date Today *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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