1. About Your Child(ren)How many children do you want to register?(Required)OneTwoThreeFourRegistering more than one child? Choose 2, 3, or 4 above, and a section will open for each child.First Child's Name(Required) First Last Date of birth(Required) Grade Completed this Year(Required)Preschool (4)Preschool (3) and potty trainedKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeAllergies or Dietary Needs(Required)Medical Condition/MedicinesSecond Child's Name(Required) First Last Second Child's Date of Birth(Required) Second Child's Grade Completed this Year(Required)Preschool (4)Preschool (3) and potty trainedKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSecond Child's Allergies or Dietary Needs(Required)Second Child's Medical Condition/MedicinesThird Child's Name(Required) First Last Third Child's Date of Birth(Required) Third Child's Grade Completed this Year(Required)Preschool (4)Preschool (3) and potty trainedKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeThird Child's Allergies or Dietary Needs(Required)Third Child's Medical Condition/MedicinesFourth Child's Name(Required) First Last Fourth Child's Date of Birth(Required) Fourth Child's Grade Completed this Year(Required)Preschool (4)Preschool (3) and potty trainedKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeFourth Child's Allergies or Dietary Needs(Required)Fourth Child's Medical Condition/Medicines2. Parent / GuardianYour Full Name(Required) First Last Relationship to child(ren)(Required)MotherFatherGrandparentLegal GuardianOtherPhone(Required)Email(Required) Enter Email Confirm Email Your Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 3. Emergency Contact & PickupName(Required) First Last Relationship to child(ren)Emergency Phone(Required)Adults authorized to pick up(Required)4. Permissions & ConsentPhoto & Video(Required) Yes - may be used in Church material No - do no photograph or film Pickup release & acknowledgement(Required) I understand that my child will only be released to me or the adults listed Emergency care authorization If I can't be reached, I authorize the church to seek emergency medical care 5. Help Us PrepareIs your family connect to UCWes? Attend regularly Have visited First time with the church How did you hear about VBS?Volunteer Interest I'd be willing to help/volunteer during VBS We offer dinner for the children and parents before VBS. We would be interested in coming for dinner Anything else we should know?6. End of form - consent & signAccuracy Confirmation(Required) The information above is accurate to the best of my knowledge Parent / Guardian signature(Required)Date(Required) CAPTCHA Δ
