Roseland Park Baptist Church
Wednesday, September 22, 2021
A Church That Cares in Picayune, Mississippi

2021 Vacation Bible School

 
Child's Name (First & Last): 
 
Parent/Guardian Name:  
Address: 
City:   State:   Zip: 
 
Phone #:  
 
Birthdate:   Age:   Grade Completed K-6: 
 
Gender:   Male   Female  

 
MEDICAL  INFORMATION:
List any allergies or other medical problems of which we should be aware (include food allergies):

 
EMERGENCY  CONTACT:
Name:   Phone:  
Name:     Phone:  
 
In case of emergency, you have my permission to seek medical treatment for my child. All expenses incurred will be paid by me, the parent or guardian. Roseland Park Baptist Church will be relieved from any liability for obtaining such medical treatment for my child.
 
 
PERMISSION TO: (Yes/No)
Photograph My Child: 
Photo Release for Advertising : 
 

DISMISSAL INFO:
Who has permission to pick up child other than yourself?  
Names / Relationship:  
 
 
Submitting this form will pre-register your child.
You will still need to go to registration table to
Check your child in, verify and sign form.