Child's Name (required) Parent/Guardian Name (required) Address City, State, Zip Home Phone Cell Phone Work Phone Birth Date Last Grade Completed in School Emergency contact person Emergency contact phone Who may pick up your child? Home Church Your Email (required)
Special Medical Conditions Family Doctor and Phone Insurance Company Insurance Policy # - Medical Aknowledgement By checking the box above, I acknowledge that I understand that my personal medical insurance is the primary coverage for all VBS events this year. In the event of an emergency situation, I authorize the representatives of Evergreen Baptist Church to seek emergency care for my child.
