BREAKER ROCK BEACH VBS • The Rock of the CMA

First Name *

Last Name *

Date of Birth

Previous Grade Completed: *

Parent/Guardian: *

Phone Number *

Home Address

Email Address

Emergency Contact: *

Emergency Contact Phone Number: *

Who may pick your child up at the end of Vacation Bible School? *

Does your child have any special needs or allergies? If yes, please list below:

May we have permission to use your child's photograph in church publications? *

Yes

No

I will sign a liability waver when I drop my child off for VBS on August 5th, 2024. *

I agree