VBS Registration

Michiana Fil-Am Church
8454 Kephart Ln
Berrien Springs, MI 49103

Ages 4 – 12
July 20 – 24
5 – 7 pm

Company

This field is for validation purposes and should be left unchanged.

Parent/Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Parent/Guardian Phone*

Other Person Authorized to Pick Up Child(ren)

First Last

Emergency Contact Name

First Last

Emergency Contact Phone

Children

Please fill out information below to register your child(ren). If you have multiple children, you can register them all at once here.

Number of Children*

Child 1 Information

Child 1 Name*

First Last

Child 1 Age*

Child 1 Birthdate*

Child 1 Allergies or Medical Conditions

Child 2 Information

Child 2 Name*

First Last

Child 2 Age*

Child 2 Birthdate*

Child 2 Allergies or Medical Conditions

Child 3 Information

Child 3 Name*

First Last

Child 3 Age*

Child 3 Birthdate*

Child 3 Allergies or Medical Conditions

Child 4 Information

Child 4 Name*

First Last

Child 4 Age*

Child 4 Birthdate*

Child 4 Allergies or Medical Conditions

Child 5 Information

Child 5 Name*

First Last

Child 5 Age*

Child 5 Birthdate*

Child 5 Allergies or Medical Conditions

Child 6 Information

Child 6 Name*

First Last

Child 6 Age*

Child 6 Birthdate*

Child 6 Allergies or Medical Conditions

Model Release

Your registration constitutes permission for the church to use your child’s picture in promotional material.