Moorings Presbyterian Church Vacation Bible School

Cost is $25 per child for children who have completed 3 year old preschool through 5th grade.

Please make check payable to Moorings Presbyterian Church 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 (mm/dd/yyyy): Child's birthday required.Invalid format.

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

Male
Female

School Grade 2009-2010:

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.

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