VBS Registration Form

Instructions PLEASE SCROLL DOWN TO SEE THE ENTIRE FORM.You may register five children on this form. To register more children, please use a second form. Fields with red asterisk must be filled in. You only need to enter a child's address if it is different from the First Child's address. After entering information about your child or children, please scroll down and enter Parental Information. In the final section, enter the names of people you authorize to pick-up your child from VBS. When done, follow final instructions and click "SUBMIT."

Child's Full Name *
Age *
Child Completed Grade *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Medical Concerns
Please describe food allergies or other medical conditions you would like the VBS staff and volunteers to know.

Child's Full Name
Age *
Child Completed Grade *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Medical Concerns
Please describe food allergies or other medical conditions you would like the VBS staff and volunteers to know.

Child's Full Name
Age
Child Completed Grade
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Medical Concerns
Please describe food allergies or other medical conditions you would like the VBS staff and volunteers to know.

Child's Full Name
Age
Child Completed Grade
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Medical Concerns
Please describe food allergies or other medical conditions you would like the VBS staff and volunteers to know.

Child's Full Name
Age
Child Completed Grade
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Medical Concerns
Please describe food allergies or other medical conditions you would like the VBS staff and volunteers to know.
Instructions To enter more children, please us a new form.

Full Name of Person Registering Child *
Relationship to Child *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Primary Phone for Contacting You *This is the phone we will use in case of emergency.
Phone Type *
HomeMobileWork
What is the quickest and surest way to reach you in case of emergency? *
Phone CallTextEmail
Email *Please provide an email. You cannot submit the form without an email. We will use the email to send you a confirmation and other VBS materials. If you cannot provide an email, please call (607) 387-7705, leave a message that you wish to pre-register your child and we will return your call within a day or two.

Instructions List Names of people you authorize to pickup your child(ren) other than yourself.
Full Name, Person 1
Contact Phone
Phone Type
HomeMobileWork
Full Name, Person 2
Contact Phone
Phone Type
HomeMobileWork
Full Name, Person 3
Contact Phone
Phone Type
HomeMobileWork

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