VBS Registration
July 23, 8:00am - 7:30pm
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Child's Name *
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Date of Birth
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MM
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DD
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YYYY
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Grade Completed
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Parent/Guardian *
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Address
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Home Phone
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Cell Phone
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Email *
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Emergency Contact Name and Number *
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Medical Information / Medication / Allergies
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I, the parent or guardian, do hereby authorize adult volunteers of First Assembly of God in Eustis as agent(s) on my behalf, to consent to any
medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clini *
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Yes, I
agree.
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Names of Brothers/Sisters Attending VBS
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Any Special Friend Your Child Would Like to be With?
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I agree, without compensation, to permit First Assembly of God in Eustis to use photographs, video images of my child, or artwork of any kind
created by my child, for use and benefit of their ministries, publications, and promotional programs. *
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Yes, I
agree.
No, I
disagree,
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Image Verification
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