Professional Development Workshop Registration Form

Register VBS 2021 "Mystery Island" ~ Heritage Baptist

Please fill in the form below:
Childs Name*

First NameLast Name
Gender*
Birthdate*

MonthDayYear
Date
Grade Completed*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parents / Guardian*

First NameLast Name
Home Phone Number*

Area CodePhone Number
Work Phone Number*

Area CodePhone Number
Cell Phone Number *

Area CodePhone Number
E-mail*
Emergency Contact*

First NameLast Name
Relationship to Child *
Emergency Contact Phone*

Area CodePhone Number
Please Place My Child With
Home Church
Food Allergies?
List Any Food Allergies
Medical Concerns?
List Any Medical Concerns
I Give Permission to Use Images and Video* - Read Below *
* PERMISSION TO USE IMAGES AND VIDEO - I hereby grant permission for Heritage Baptist Church to record sounds, images, or video of my child while attending Vacation Bible School. I also give permission for Heritage Baptist Church at its sole discretion, to use these sounds, images, or videos in publications (including print, websites, and social media platforms) owned by Heritage Baptist Church.
Should be Empty:

Register VBS 2021 "Mystery Island" ~ Heritage Baptist