Gaston Baptist Church

June 10-14, 2024 | Grades K-6 | 9AM-12PM

Parent/Guardian Name: (Required)

Parent/Guardian Phone Number: (Required)

Child's First and Last Name: (Required)

Address (Required)

Emergency Contact 1: (Required)

In the event of an emergency, who do we contact? List name and number.

Emergency Contact 2: (Required)

In the event of an emergency, who do we contact? List name and number.

Allergies or Medical Info: (Required)

Grade Recently Completed: (Required)

Medical Release: (Required)

I give my permission for the VBS staff to administer basic first aid to my child (named above) in the event of an injury. I understand that the VBS staff will contact emergency services in the event of a significant injury and all expenses for such emergency services will be paid by me.

Photography/Video Release: (Required)

I authorize, Gaston Baptist Church permission to copyright and use photographs/videos taken at VBS of the minor designated above in any manner or form for any purpose lawful at any time.

Parent/Guardian Signature: (Required)

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Date: (Required)

Enter today's date.

Gaston Baptist Church

1908 Gaston Road, Booneville, MS 38829