Moorings Presbyterian Church Vacation Bible School

Cost is $25 per child for children who are 4 (by Septemebr 1, 2011) through 5th grade.

Please make check payable to Moorings Presbyterian Church (Please note VBS) and mail to:

791 Harbour Dr, Naples FL 34103, Attn: VBS

Please complete a separate form for each child.

Confidential Registration Form/Emergency Card

Personal Information:

Child's Name: Child's name required.

Nickname/Preferred name to be called:

Parent/Guardian: Guardian required.

Address: Address required.

City: City required. State: State required. Zip Code: Zip code required

Home Phone: Phone No. required. Cell Phone: Invalid format. Email Address: A value is required.

Child's Age: Child's age required. -------Child's Birthday (m m/dd/yyyy): Child's birthday required.Invalid format.

Height ft In -----Weight Pounds ----- Hair -------Eyes

Male
Female

School Grade 2010-2011:

Siblings:

Home faith community (if any):

Please select child's T-Shirt size

Youth XSmall

Youth Small

Youth Medium

Youth Large

Youth XLarge

Emergency Contact Information:

In case of an emergency (when the parent cannot be reached), please contact:

Emergency Contact 1 Name: Emergency Contact required.

Telephone Number: Emergency contact phone number required.Invalid format.

Relationship to Child: Emergency contact relationship required.

Emergency Contact 2 Name:

Telephone Number:

Relationship to Child:

Physician: Name Physician's name required.

Phone: Physician's phone number required.Invalid format.

Dentist: Name Dentist's name required.

Phone: Dentist's phone number required.Invalid format.

Pick-Up Information:

Person responsible for picking up child at the end of each VBS day:

Name: Pick up persons name required.

Telephone Number: Telephone number required.Invalid format.

Special Instructions:

Please list any allergies/medical needs the VBS staff should be aware of:

Please list any medications your child is currently taking:

Please list any medical conditions your child has:

Tell us anything special you'd like us to know about your child:

Special needs/circumstances:

This is my child's first large group experience other than Sunday school.

Yes
No

ONE friend my child would like to be with:

Volunteer Information:

Please Indicate below if you would like to volunteer: (Please select one)
Site Guide
Assistant
Registrar
Other

Days available:

If the form does not submit please look over form for missing information. Anything in Red Must Be filled in.

You will be redirected back to the Moorings Presbyterian Church Website when your form has been successfully submitted.