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VBS Registration 2011

ADULT VOLUNTEERS: Contact Ms. Lori Lively directly [928-6204] to register yourself and/or your children.

Note: After the Registration Form you will then be directed to a secure site for Payment.
The fee is $15 per child until May 25th. Registration after this date increases to $20 per child.

Please be prepared to have your credit card information available.

Registration presumes parental consent for the child's image to be published. This includes, but is not limited to, Mercy Church and School bulletin, newsletter, and website. You must check one of the options under Publication Permission
.
Please register and pay by LAST Name and/or by HOUSEHOLD

Publication Permission
 
  I Do Give Permission
  I DO NOT Give Permission

 *Last Name
  

Child's Name & Grade Completed in 2010-2011
 *
Child 1 Name & Grade
  

Child 2 Name & Grade		  

Child 3 Name & Grade		  

Child 4 Name & Grade		  

Address Where Children Live
 *Street  
 *City / State / Zip Code  

Parent's Name & Contact Information:
 *Father - Name & Phone  
 *Mother - Name & Phone  
 *Emergency Name & Number -[other than parent]  

Medical Allergies/Conditions
Child 1 Name & Medical Info.  
Child 2 Name & Medical Info.  
Child 3 Name & Medical Info.  
Child 4 Name & Medical Info.  
 
  * Indicates required fields
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