Child's Name:

Name
Date of Birth
Grade Completed

Parent's Names & Addresses:

Phone Number:   Alternate Phone Number: 

Emergency Contact Person (in addition to parents):

Name
Title
Work Phone
Home Phone

Food Allergies (select one):  Yes No   List Food Allergies:

Medical Concerns (medication, illness, etc.): 

Family Doctor:

Name
Title
Organization
Work Phone
FAX

Siblings or friends attending VBS (name and grade):

Home Church: 

People allowed to pick up child:

Name
Work Phone
Home Phone

Name
Work Phone
Home Phone

Name
Work Phone
Home Phone

I hereby grant the VBS leaders at St John Lutheran Church permission to photograph the minor here designated in any manner or form for any lawful purpose associated with this VBS program:  Yes No