Langford Community Church

Child's name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Child's name

First Name

Last Name

Date of birth

MM

DD

YYYY

Child's name

First Name

Last Name

Date of birth

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Phone *

(###)

###

####

Persons approved for pick up after VBS *

Note that VBS will run from 8:45-12:15. We are not able to provide child care beyond those times.

First Name

Last Name

Pick up phone

(###)

###

####

Persons approved for pick up after VBS

Note that VBS will run from 8:45-12:15. We are not able to provide child care beyond those times.

First Name

Last Name

Pick up phone

(###)

###

####

I give permission for photos and videos of my child (or children) to be taken during VBS and shared afterward for promotional and church use. *

Yes

No

Please enter your name here in lieu of a signature. *

First Name

Last Name

By checking the box below, I give my consent electronically and have entered my name in lieu of a signature. *

I agree and give my child permission to participate.