Child's Full Name (required)

Child's Age (required)

Grade Entering Fall 2019 (required)

Child's Gender (required)

Parent's Full Name (required)

Complete Address (please include your City, State, and Zip) (required)

Your Email (required)

Phone Number (required)

Child's Birthday (required)

Emergency Contact Name and Phone # (required)

Health Restriction/Severe Allergies (if any)

Do you want to be with a friend? (must be same age) (required)

Friend's full name (required)

My child may be photographed to be used only by Wesley Chapel(required)

Do you attend a church regularly? (required)

Where do you attend? (required)

May we Contact you for Future Events and Services?(required)

Any additional information you would like to provide

Parental Release: I give my permission for my child to participate in the 2019 VBS Program at Wesley Chapel UMC. I will not hold the church nor any person responsible for accident or injury during the time my child is attending VBS at Wesley Chapel. I give them permission to sign for medical treatment in case of emergency if every attempt to reach me (the parent) or the other emergency contact fails. (Please type your name and date in the space provided)