VBS | St. John's Reformed Church Loysburg

Vacation Bible School Registration - Summer 2025

Please Submit a Form for Each Child

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Address

Child's Name:

Birthday

Month

Day

Year

Age (at time of VBS)

Grade Level (Entering in Fall)

T-Shirt Size

Emergency Contact

Emergency Contact Phone

Relationship to Child

Allergies or Medical Conditions (if none write "NO")

Medications (if any)

Primary Physicians Name & Phone (optional)

Church Affiliation (optional)

Pickup Authorization (Please list anyone authorized to pick up your child) (optional)

Photo/Video Release: I grant permission for my child's photo to be used in VBS materials and church media

Yes

In case of emergency, I authorize the VBS staff to seek medical care for my child

I understand the church is not liable for injuries beyond first aid provided on site.