Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Number or Home Number *

Additional can be added in Notes.

(###)

###

####

Child Date of Birth *

MM

DD

YYYY

Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 *

(###)

###

####

Emergency Contact #2 *

First Name

Last Name

Emergency Contact #2 *

(###)

###

####

Dismissal Name *

Name of the Person(s) permitted to pick up child from VBS

First Name

Last Name

Photo Release *

Mt. Chestnut Presbyterian Church has permission to use photographs of my child in publicity VBS material. I understand that images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. Clicking will act as my signature.

YES

NO