VBS 2022 June 13th - 17th, 6:00pm - 8:30pm Age 4 thru Grade 6 Child's Information Child's Full Name * Sex * Male Female Fall School Grade * Age 4KindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth Grade Birthday * Age as of June 13th * Mother's Information Mother's Full Name * Mother's Address * Mother's Email Address Mother - May we Email You? Yes No Mother's Home Phone * Mother's Cell Phone * Mother - May we Text You? Yes No Another Number other than Mother * Father's Information Father's Full Name * Father's Address (if different than Mother) * Father's Email Address Father - May we Email You? Yes No Father's Home Phone * Father's Cell Phone * Father - May we Text You? Yes No Another Number other than Father or Mother * Permission for Alternate Pick up other than Mother or Father Name * Relationship * Cell/Home Phone * May we Text You? * Yes No Medical Information Allergic to any Medications? * YES NO Diabetic? * YES NO Convulsive Disorder? * YES NO Asthma? * YES NO Allergies? * YES NO Tetanus Shot Current? * YES NO List any other medical problems we should be aware of * List any exercise your child should not do * CONSENT FOR MEDICAL TREATMENT By signing my name below, I give permission for the staff of Mill Creek Baptist Church to obtain and administer such medical aid, including that of a licensed MD, as might be required for the immediate care of my child in an emergency. I understand that every effort will be made to contact me. CONSENT FOR MEDICAL TREATMENT Mother's and/or Father's Signature * CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
