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June 22-26, 2008

On-line Registration

PLEASE COMPLETE A SEPARATE FORM FOR EACH CHILD!

  1. Child's Information:

    First Name
    Last Name
    Date of Birth
    Sex Male Female
    Grade in Fall



  2. Father's contact information:

    First Name
    Last Name
    Cell Phone
    Home Phone
    E-mail

     

  3. Mother's Contact Information:

    First Name
    Last Name
    Cell Phone
    Home Phone
    E-mail

     

  4. Home Address:

     
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country

    FOR QUESTIONS 5-8 and 12 please put commas between items.

    DO NOT PRESS ENTER and put on new lines! Thank you!

     

    

  5. 

    
Known Allergies?
    

    




    

    


    
    

    

  6. 

    
Medical Concerns and Medications
    

    




    

    


    
    

    

  7. 

    
Others who may pick up child:
    

    




    

    


    
    

    

  8. 

    
Our family will be ______________________before activities begin:
    

    


 eating dinner at HPC

    

 not be eating at HPC

    

    
    

    

  9. 

    
Please contact us so we can volunteer!
    

    


 Yes

    

 No

    

    
    

    

  10. 

    
Parents would be interested in an adult class:
    

    


 Yes

    

 No

    

    
    

    

  11. 

    
Topics for adult class we would be interested in?
    

    




    

    


    
    

    

  12. 

    
Consent: I hereby consent for my child to participate in the Heritage Presbyterian Church Vacation 
Bible School program and in the event of an emergency, authorize the Heritage 
Presbyterian Church Vacation Bible School directors and the Heritage 
Presbyterian Church staff to seek any medical attention for my child. (Submission 
of this form replaces signature.)
    

    


 Yes

    

 No

    
    

    

    










Author: Clay Gunter
Copyright © 2008 Heritage Presbyterian Church. All rights reserved. 

Revised: 
04/16/08