HIGHLANDS BAPTIST CHURCH
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Highlands Baptist Church
2017 VBS Registration
Child Information
*
Indicates required field
Child's Name
*
First
Last
Birthdate
*
MM/DD/YYYY
Age
*
Gender
*
Select one
Male
Female
Last Grade Completed
*
VBS Class
*
Preschool - K
1st - 3rd Grades
4th and 5th Grades
Select the Class you would like your child to attend during VBS.
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Select one
Zip Code
*
Transportation Type
*
Select one
Bus Rider
Parent Pick-up
My child would like to be in class with the following friend(s)
*
The following sibling(s) will also be attending VBS with my child
*
Comment
*
My child attends the following church:
*
Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Home Phone
*
Mobile Phone
*
Email
*
Emergency Contact Name
*
Phone Number
*
Relationship to Child
*
Medical Information
Child Has Allergies
*
Select one
Yes
No
If "Yes", list allergies
*
Child Has Medical Condition(s)
*
Select One
Yes
No
If "Yes", list conditions
*
Insurance Company
*
Policy Number
*
Disclaimer
The undersigned gives permission to his or her child to participate in the above named activity and releases Highlands Baptist Church, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by the undersigned for any member of his family, in attendance, and the undersigned agrees to defend and indemnify Highlands Baptist Church, its officers, employees, and agents, from any liability or loss they might sustain by reason thereof. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the director of children's ministry to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above.
I have read and agree to the above disclaimer:
*
Select one
Yes
No
Submitted by:
*
Acknowledgement
By submitting this registration form you agree that any photographs taken of your child at or during this event are the property of Highlands Baptist Church and may be used in future publications as deemed appropriate.
Submit
Home
About Us
Church Covenant
Live
Sermons
Sunday/Wednesday Worship
Revelation Study
Giving
Contact Us
Update Contact Info for Calling System
Photos
Resources
Drivers
Youth