VBS Registration – Elgin-Portland Pastoral Charge

* indicates required field

Child's First Name*

Child's Last Name*

Age:*

Allergies*

Mailing Address:*

Parent's Email*

Emergency Contact #:*

Please let us know who will be picking up your child each day:

Monday:

Tuesday:*

Wednesday:*

Thursday:*

Friday:*

Photo Consent:*

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 Full Name:*

Signature:*

Checking this box implies that I, the Parent named above, has signed this form.

CAPTCHA Code:*