Register for VBS | Piedmont Church of God

Child's Name (Required)

Gender (Required)

Select One:

Male

Female

Birthday (Required)

Birthdate

Age Group (Required)

Please select one:

Last School Grade Completed:

Please enter Grade:

Parent's Name(s): (Required)

Please list Name of Mom / Dad / Guardian:

Address (Required)

Phone Number / Contact #: (Required)

Cell Phone / Home #:

Allergies or Medical Info

Please list any allergies your child may have. (Please include food allergies)

Emergency Contact (Required)

In the event of an emergency, who do we contact? Phone number?

Do you have a Home Church? / Where do you attend?

Persons who are authorized to pick up your child:

Please type the Name or Names of those who have permission to pick up your child:

Will your child need a ride on the Church Van?

If you need transportation, please let us know.

Solve 5 + 1 = ?

Piedmont Church of God