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Home
About
Kids
VBS
Grow
Mission
Calendar
Contact
Vacation Bible S
chool 2021
For ages 3-12
Monday June 7th - Friday June 11th
9:00-11:30 am
Register for FREE Today!
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Indicates required field
Name of Child
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Date of Birth (mm/dd/yy)
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Last Grade Completed
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Age
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Name of Child
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Date of Birth (mm/dd/yy)
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Last Grade Completed
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Age
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Name of Child
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Date of Birth (mm/dd/yy)
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Last Grade Completed
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Age
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Name of Child
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Date of Birth (mm/dd/yy)
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Last Grade Completed
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Age
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Parent or Guardian Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone
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Cell Phone
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Email
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Emergency Contact Name & Number
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Special Needs / Allergies / Other Concerns
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Home Church (If you attend a local church)
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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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Yes
No
Electronic Signature
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Typing your name here is an electronic signature for Coudersport Alliance Church VBS registration
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