| But God Ministries (Sponsor)

Child's Name*

First Middle Last

The name you go by*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent Name*

First Middle Last

Home Phone

Cell Phone*

Work Phone

Email Address*

Child's Date of Birth*

Grade Completed*

Have you, your child, or anyone else in your household been exposed to COVID-19?*

Have you, your child, or anyone else in your household displayed any symptoms of COVID-19 in the last 14 days?*

Have you, your child, or anyone else in your household been to a high risk area in the last 14 days?*

Have you, your child, or anyone else in your household traveled outside of the country in the last 14 days?*

Please tell us anything important that we should know about your child:*

Emergency Contact Information

Emergency Contact #1*

Street Address for Emergency Contact #1*

Phone for Emergency Contact #1*

Emergency Contact #2*

Street Address for Emergency Contact #2*

Phone for Emergency Contact #2*

Does your child have any allergies or medical conditions that we should be aware of?*

Customized VBS kits will be mailed directly to students.

Kits will be created according to your child's interests. Please select your child's FIRST choice:*

Kits will be created according to your child's interests. Please select your child's SECOND choice:*

Signature*

Understand that by signing this form you are stating that all the information you have given on this form is true and that you agree with the VACATION BIBLE SCHOOL LIABILITY AND PERMISSION FORM.

Date Signed*