Register Your Child

**By filling out the registration portion of this form, Berea Baptist Church is released from any unforeseen and accidental damages along with contact information in case of an accident. The parents or guardians authorize the ministry staff of Berea Baptist Church to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named on this registration form. By registering your child(ren) for VBS, you undertake and agree to indemnify and hold blameless the ministry staff of VBS, Berea Baptist Church, and its Pastors from and against any illness, disease, loss, damage or injury suffered by the participant as a result of being part of the activities of the Berea Baptist Church, as well as of any medical treatment authorized by the supervising individuals representing the church.

We found some errors when you submitted your information. Please see below and fill in the information needed.

Parent Personal Information

Parent First Name:

Parent Last Name:

Address 1:

Address 2:

City:

Country:

State:

Zip:

Email:

Re-Enter Email:

Home Phone Number: (xxx-xxx-xxxx)

Cell Phone Number: (xxx-xxx-xxxx)

Other Phone Number: (xxx-xxx-xxxx)

Emergency Contact

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Phone 1: (xxx-xxx-xxxx)

Emergency Phone 2: (xxx-xxx-xxxx)

Alternate Pickup First Name:

Alternate Pickup Last Name:

Alternate Pickup Phone: (xxx-xxx-xxxx)

Other Information

Home Church (If Applicable):

Is there any other important information that we should know?: