Register for VBS!

July 6-10 from 6 to 8pm. Always fun, always free!

Child Name *

First

Last

Gender

• Male
• Female

Birthday

Age *

Last Grade Completed

Address

City, State and Zip Code

Parent/Guardian Name *

First

Last

Phone Number

Email *

Emergency Contact

Relationship to Child

Emergency Phone Number

Who is approved to pick up your child?

Name of your home church

Food Allergies

• Yes
• No

List food allergies, if applicable

Medical Concerns

• Yes
• No

medical Who this

Please explain medical concerns, if applicable

I grant permission for Homer Independent Baptist Church (HIBC) to record sounds, images or video of my child while attending this VBS program. I also give HIBC, at its sole discretion, to use these sounds, images or videos in publications (including print, website and social media platforms) owned by HIBC in relation to this VBS program.

Parent/Guardian First and Last Name and Date

Submit