VBS 2017 Registration VBS 2017 - MARKETPLACE Please fill out this form once for each child attending VBS, and make sure you see a thank you confirmation in this spot once you register. Child's Name* First Last Gender* Male Female Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rising Grade*Rising 1st GradeRising 2nd GradeRising 3rd GradeRising 4th GradeRising 5th GradeRising 6th GradeParent/Guardian - please include area code. Example: (423) 123-4567*NameCell Parent/Guardian Email* Emergency Contacts - please include area code. Example: (423) 123-4567*NameCell Phone Allergies/Medicines/Special Needs* None Food Allergy Drug Allergy Current Medicines (for emergency purposes only) Special Needs Please elaborate on what you checked: Allergies/Medicines/Special Needs*Please hand your labeled EPI Pen to the Nurse in the car line each day.In the case of an allergic reation, please administer 1 dose of No Dye, Liquid Benadryl until I arrive.* Yes No Medical Information*PhysicianPhone Number Click the + beside phone number to add more physicians. Phone number example: (423) 123-4567Friend Request (optional)We will try to honor ONE request with a friend in the same grade. However, the friend must register also!How is your child getting home?* Walking Parent Pickup Sitter Pickup Neighbor Pickup Grandparent Pickup If you clicked Sitter, Neighbor, or Grandparent Pickup for your child, please provide the cell phone number.*Parent or Guardian, would you like to volunteer for VBS?* Yes, Kids Group Yes, Craft Booth No Are your Youth (Rising 7th Grade - Rising College) interested in being a Youth Volunteer?* Yes No If you clicked yes, you will need to fill out the Youth Volunteer Form. Please go back to the VBS page and fill out the Youth Registration Form.I, the parent/guardian of child being registered, authorize the adult leaders of Signal Mountain Presbyterian Church (SMPC) VBS, to act as my agent to consent to emergency treatment. I understand that every attempt will be made to contact the parent/guardian in the event of any emergency. I therefore assume all responsibility for decisions so made, and the emergency care or treatment secured for my child. This includes SMPC to administer 1 dose of no dye, liquid Benadryl in case of allergy reaction.Disclaimer* Please check that you have read and agree to the above disclaimer.