Virtual VBS Registration Form
Registration Date
-
Month
-
Day
Year
Date
Student Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Grade Level
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload your recent photo
Browse Files
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Choose a file
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of
Parent/Guardian Information
Name 1
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name 2
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Church Name
Authorized person who can pickup the child on dismissal
First Name
Last Name
What are the tools that you have in order to interact properly?
Desktop pc/Laptop
Smart phone
Landline
Headphone
Microphone
Internet Connection
Webcam
Other
How did you learn about this virtual study?
Desktop pc/Laptop
Smart phone
Landline
Headphone
Microphone
Internet Connection
Webcam
Other
Payment Detail
Registration Fee
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( X )
Two Weeks
$70.00
$
70.00
Quantity
1
2
3
4
5
6
7
8
9
10
Three Weeks
$100.00
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
One Month
$150.00
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Method
Please Select
Cash
Check
Credit Card
PayPal
Wire Transfer
Bank Payment
Agreement
I allow my child to participate in this program or bible study during vacation time.
All fees are non-refundable.
I authorize the school, bible study conductor, volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.
I release the school from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Would it be okay if we take photos and videos of the participant during the activity which will be posted in our social media account?
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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