VBS Registration

Fields marked with an * are mandatory.
* First Name
* Last Name
Name Used
* Birthday
School Attending
* Grade - Last Grade COMPLETED
Family Information
* Address
* City, State, Zip
* Home Phone
* Email
Parent/Guardian #1
* First Name
* Last Name
* Phone
Parent/Guardian #2
* First Name
* Last Name
* Phone
Persons Authorized - - - to pick child up - - - from camp.
Emergency Information
* Emergency Contact Name
* Emergency Phone
* Doctor's Name
* Doctor's Phone
* Insurance Company
* Policy Number
Additional Contacts List Name and Phone for additional persons to be called in an emergency if your Main Emergency Contact cannot be reached.
Emergency Medical Conditions List any allergy or medical condition that might require emergency treatment.
Other Medical Info List any allergies or medical conditions that would need to be given to EMERGENCY SERVICE PROVIDERS in the event of an emergency.
Medications - List any medications the participant is taking. This is information for EMERGENCY SERVICE PROVIDERS only. The Camp personnel will NOT administer medications to participants. The Camp does not assume responsibility for any inhalers or other medications taken or not taken by the participant.
Special Diet Concerns
Other Concerns If there are any other issues, child custody problems, or other special concerns affecting your child or your child’s ability to participate in Camp activities, please describe them here:

Type the characters in the box
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