Fleming Island UMC - VBS Registration

Stellar VBS Registration

Parent & Household Information

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Emergency Contact / Relationship

Emergency Contact Phone

Alternate Pick--up #1 Name

Alternate Pick-up #1 Phone Number

Alternate Pick-up #2 Name

Alternate Pick-up #2 Phone Number

Home Church Affiliation

Medical Release - I hereby give permission to Fleming Island UMC to take appropriate medical action in case of an emergency if they can not reach me or it a life-threatening emergency. Please type "I Give Permission" and your name.

Photo Release - I hereby give permission for Fleming Island UMC to use photos of my child (NO NAMES) in VBS Promotion on the church website, social media, and in print. Please indicate "yes" or "no" and type your name.

Child Information

Child #1

First & Last Name

Goes By

Date of Birth

Age

Gender

Grade Entering

Allergies and Reactions

My Child has an EpiPen or inhaler

Shirt Size

Child #2

First & Last Name 2

Goes By 2

Date of 2

Age 2

Grade Entering 2

Allergies & Reactions 2

My Child has an epipen or inhaler 2

Shirt Size 2

Child #3

First & Last Name 3

Goes By 3

Date of Birth 3

Age 3

Gender 3

Grade Entering 3

Allergies & Reactions 3

My Child has an Epipen or Inhaler 3

Shirt Size 3

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