VBS 2024 Registration Form

Please submit one form for each child.

• Child Information

• Child's Name:*
  First Last
• Gender:*
  • M
  • F
• Date of Birth:*
  MM123456789101112

  DD12345678910111213141516171819202122232425262728293031

  YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
• Grade Completed?*
  Completed Preschool and going to Kindergarten this fall!Transitional Kindergarten (TK)Kindergarten - Limited Availability1st grade2nd grade3rd grade4th grade5th gradePreschool 3's & 4's (Volunteers Only)Childcare (Babies-2's) (Volunteers Only)
• Children must be ages rising K – 5th grade completed to attend VBS.
• What does your child like to be called?
• Please name one (1) friend to place your child with: (If possible)
• Where do you attend school?*

• Extended Care - Wait List Only

• *CURRENTLY ON A WAIT LIST FOR EXTENDED CARE.* Will you need extended care for your child (rising K - 5 Grade Completed ONLY) before and / or after VBS? ($150 fee)*
  • Yes
  • No
• If Yes, When?
  • Before (7:30-8:45am)
  • After (12:00-5:30pm)
  • Both (7:30am-5:30pm)

• Medical Information

• Any major allergies (including food) or medication needs (during VBS hours) we should be aware of?*
  • Yes
  • No
• If Yes, please describe:*
• Any Illness or Activity Restrictions?*
  • Yes
  • No
• If Yes, please describe:*
• Do you have a Preferred Physician? (In case of emergency)
  • Yes
  • No
• If Yes, Name of Physician?*
  First Last
• Physician's Contact Phone:*

• Parent Information

• Parent Name:*
  First Last
• Parent Name:
  First Last
• Primary Contact Phone: (###)###-####*
• Email:*
• Address:*
  Street Address City 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 State ZIP Code
• Is someone other than yourself authorized to pick up your child?*
  • Yes
  • No
• If yes, Name:*
  First Last
• Authorized Contact Phone:*
• Are you a Providence Member?*
  • Yes
  • No
• Do you have a home church?
  • Yes
  • No
• If yes, Name of church?

• Additional Information

• Please tell us how you heard about VBS!
  Select OneFrom a FriendEmailPrintSocial MediaOther
• If Other, please describe:
• Is there anything you want the VBS Director to know so we can better care for your child?
  (Answers to this question will be confidential)
• By submitting this form, I / we the caregivers of the above named child do hereby give our approval for our child's participation in the Vacation Bible School program of Providence Baptist Church. In case of an illness, accident or medical emergency, and the Parent / Preferred Physician listed above cannot be reached, I / we authorize the staff to secure such medical attention and care of our child as may be necessary. I / we understand that caregivers will assume responsibility for payment of any medical fees incurred.

  I / we also understand that as a participant, my child may be photographed or videotaped during campus activities and these photos/videos may be used in promotional materials, social media, group activities, and/or official church website.

• Today's Date*
  MM slash DD slash YYYY
• Signature
  (Please type name)
• Phone
  This field is for validation purposes and should be left unchanged.