EmailMe Form - St. James Vacation Bible School (VBS) Registration

Student Name *

First Last

Parent / Guardian *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Home Phone *

### - ### - ####

Preferably one that receives text

Cell Phone *

### - ### - ####

Preferably one that receives text

Work Phone *

### - ### - ####

Preferably one that receives text

Birth Date *

MM / DD / YYYY

Last School Grade completed *

Home Church *

Friends of your Child at St. James *

Does the Student have any health conditions (asthma, etc….)? *

Yes

No

If yes, please list:

Emergency Contact #1 *

First Last

Emergency Contact #1 Phone *

### - ### - ####

Emergency Contact #2

First Last

Emergency Contact #2 Phone

### - ### - ####

Dismissal Information *

Name(s) of person(s) who may pick up this child from VBS

SPECIAL NEEDS CONSIDERATIONS

If your child has special needs, please complete this section.

1. How does your child best communicate his/her needs? *

2. How does your child communicate when she or he does not want something?

3. What are your child’s strengths?

4. What are your child’s challenges?

5. What does your child like to do?

6. How does your child socialize/make friends?

7. Are there any aggressive/inappropriate behaviors we should know about?

8. Are there any triggers of inappropriate behaviors?

9. What are some things that help hold your child’s attention?

10. Does your child have any dietary or environmental issues we should be aware of?

11. Does your child have physical limitations? If so, briefly describe :

12. Are there medical issues we need to be aware of (seizures, diabetes, medications)?

13. What are some ways we can help your child learn about God’s love?

14. Is there anything else you would like for us to know?

SIGNATURES

Note: Parent/Guardian signatures are only required for Students under the age of 18.

I give the Generations Department consent to use my child/children pictures in any social media or in videos used for any ministry event *

Yes

No

Parent/Guardian (Digital) Signature *

Clear

The information contained in this Student Registration Form is correct to the best of my knowledge.

I, the undersigned, understand that the personal information in this application will be held confidential by the Generations Department.

Date Time *

MM / DD / YYYY

Parent/Guardian (Digital) Signature

Clear

The information contained in this Student Registration Form is correct to the best of my knowledge.

I, the undersigned, understand that the personal information in this application will be held confidential by the Generations Department.

Date Time

MM / DD / YYYY