Vacation Bible School Registration Form • Calvary Church Martinsburg

Director Contact: Chelsea Payton (304) 267-4542 or calvaryum@comcast.net

Child Must be Potty Trained in order to attend

Child's Name *

Child's Age *

Grade Child will be attending *

Permit Childs Picture Taken *

Child's Birth Date *

Parent/Guardian(s) Information

Parent Name 1 *

Home Address

Mailing City

Mailing State

Mailing Zip Code

Phone Number *

Mobile Number *

Work Number

Email Address

Preferred Contact Method *

Parent Name 2

Home Address

Mailing City

Mailing State

Mailing Zip Cose

Phone Number

Mobile Number

Work Number

Email Address

Preferred Contact Method

EMERGENCY INFORMATION

Emergency Contact 1 *

Phone *

Emergency Contact 2

Phone

Doctor

Phone

Allergies or Special Needs *

DISMISSAL

Who may pick up your child at the end of each VBS day?

Name *

Relationship *

Name

Relationship

Parent/Guardian Signature