VBS - COUDERSPORT ALLIANCE CHURCH

Vacation Bible School 2019

For ages 3-12
Monday June 17th - Friday June 22nd
9:00-11:30 am

Register for FREE Today!

* Indicates required field

Name of Child *

Date of Birth *

Grade Completed *

Age *

Name of Child *

Date of Birth (mm/dd/yy) *

Grade Completed *

Age *

Name of Child *

Date of Birth (mm/dd/yy) *

Grade Completed *

Age *

Name of Child *

Date of Birth (mm/dd/yy) *

Grade Completed *

Age *

Parent or Guardian Name *

First

Last

Address *

Home Phone *

Cell Phone *

Email *

Emergency Contact Name & Number *

Special Needs / Allergies / Other Concerns *

Home Church (If you attend a local church) *

I further acknowledge that any child registered on this form, as a participant in Vacation Bible School at Coudersport Alliance Church, may be photographed or captured on video during the Vacation Bible School program and activities. I hereby grant full permission to Coudersport Alliance Church to use photographs or videos in print, electronic, online, or other public media of the child registered on this form and further release Coudersport Alliance Church from any and all liability connected with the authorized use of words and image of the child registered on this form.

I have read and agree to the above Liability Release and Photography/Video Authorization *

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Electronic Signature *

Submit

Vacation Bible School 2019

Register for FREE Today!

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