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FTC - VBS Online Student Registration Form

If you or your child would like to participate in VBS as a Student Learner, please complete the following form. If you are under 12, please have your parent or guardian complete the form. (Please fill-out this form for each student attending).

Student's First Name: *

Student's Last Name:*

Parent/Guardian Name:*

Address:*

City:*

State:*

Zip:*

Home Phone (ex. 555-555-5555):

Cell Phone (ex. 555-555-5555):

Email:

Student's Birthday (ex. 00/00/2000):*

Age Group*

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Gender:*

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Allergies, Medical, & Special Needs (Leave Blank if None):

May we have permission to treat or acquire medical assistance (911) if needed? *

Select an option

Emergency Contact Name (1):*

Emergency Contact Phone (1):*

Emergency Contact Name (2):

Emergency Contact Phone (2):

Authorized Pickup Persons:*

Transportation Needed?*

Select an option

Student Will Attend VBS On?*

Siblings Attending?*

Select an option

Do you attend Church?

Select an option

If so, where?

May we have permission to photograph or video the student. Note: The photo(s) or video(s) may be used for church related media and/or publications?

Commments:

Authorized Parent / Guardian / Adult E-Signature: *

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