When?

July 11th – 13th

FROM 6:30PM UNTIL 8:30PM

Where?

4160 Zion Church Rd

Concord, NC 28025

704-793-9055

Call this number for anymore questions. RSVP by 6/24

VBS Registration Form

Please fill out form in it’s entirety

Parent/Guardian Information
First Name:
Last Name:
Address:
Home Phone:
Cell Phone:
Emergency Contact Name:
Home Phone:
Cell Phone:
1st Child Information
First Name:
Last Name:
DOB:
Age:
Medical Information: Any Medical or allergy information we need to know? or enter "NONE"
Does your child have any special needs or requirements? Please list below or enter "NONE"
2nd Child Information
First Name:
Last Name:
DOB:
Age:
Medical Information: Any Medical or allergy information we need to know? or enter "NONE"
Does your child have any special needs or requirements? Please list below or enter "NONE"
3rd Child Information
First Name:
Last Name:
DOB:
Age:
Medical Information: Any Medical or allergy information we need to know? or enter "NONE"
Does your child have any special needs or requirements? Please list below or enter "NONE"
4th Child Information
First Name:
Last Name:
DOB:
Age:
Medical Information: Any Medical or allergy information we need to know? or enter "NONE"
Does your child have any special needs or requirements? Please list below or enter "NONE"
In the event of illness or accident, having parental responsibility for the above named child(ren), I give permission for the first aid to be administered where considered necessary by a person trained in first aid, if available, or medical treatment to be administered by a suitably qualified medical practitioner. I understand that by my child(ren)'s participation in this church youth activity his/her picture could be taken and used in press releases, brochures, video, CD/DVDs, websites, etc. for publicity use only.
Parent Digital Signature:
Date: