VBS Registration – Elgin-Portland Pastoral Charge

Child's Name*
First Last
Age*
Please enter a number from 5 to 13.
Allergies
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent's Email
Emergency Contact #*
Enter Name of Person Picking Child up each day
Tuesday*
First Last
Wednesday*
First Last
Thursday*
First Last
Friday*
First Last
Consents
Parent's Name*
First Last
Photo Consent
I agree to the following:
I give permission for the photograph(s) and/or video images(s) of myself, taken by event organizers or participants, to be used as memory or promotional material in various United Church of Canada print and electronic resources.
Parent's Signature*
- Signed
Checking the box above implies that I, the Parent named above, has signed this form.
CAPTCHA

Enter Name of Person Picking Child up each day