VBS – Heber Springs Baptist Church

Child Name *

First

Last

Age

Selected Value: 5

Date of Birth *

mm-dd-yyyy

Incoming School Grade *

Address *

City *

State *

ZIP Code *

Parent/Guardian *

First

Last

Primary Phone *

Alternate Phone

Confirm Email

Do you have a Church home?

If Yes, Where?

Emergency Contact *

First

Last

Emergency Contact Number *

Medical Allergies *

Enter None if not applicable

I give permission for photos or videos of BlastOff VBS activities which may contain my child to be used on Heber Springs Baptist Church media platforms. *

Questions? If you have any questions about BlastOff VBS 2022, please let us know.

Being the legal guardian of the minor named herein, by check box and signature I give Heber Springs Baptist Church and/or its sponsors the authority to secure any medical and/or surgical treatment for the child names above that is determine necessary in the event of an emergency, sickness, or accident. *

I Agree to the statement above

Signature *

First

Last

This signature authorizes that I am legal guardian of the minor names herein.