Registration | Good Shepherd Baptist Church

GSBC BACK YARD BIBLE SCHOOL

Back Yard Bible School:

1855 Canter Drive, Riner VA (map)

Kickoff Party - Sunday, July 24 5-7:00 p.m.

Hot dogs, Water Slide / Slip-n-slide, facepaint, fingernail paint, bubbles, etc.

BYBS - Monday, July 25 - Wednesday, July 27 from 6:30 - 8:30pm

Ages 4 through 12 (rising 6th graders)

Children under the age of 4 are welcome, but must be accompanied by a parent.

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Child's Information

First Name (Child)*

Last Name (Child)*

Date of Birth (Child)

Format is MM-DD-YYYY (select using Calendar or type in directly)*

Gender (Child)*

Grade Completed

What is the last Grade that your child completed? (if in school)*

Parent's Information

Name (Parent)*

Email Address*

Primary Phone

Secondary Phone

Street Address

City

State

Zip

Emergency Contact

Emergency Contact Name

This should be someone OTHER THAN the parent listed above. (Contact will be attempted with Parent first)*

Emergency Contact Phone*

Emergency Contact Address

Persons Authorized to Pick up Child

Emergency Medical Authorization

I/we the parent(s)/guardian of this child authorize Good Shepherd Baptist Church to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to my/our child or ward if an emergency occurs when I/we cannot be located immediately. I/we also understand that this agreement covers only those situations that are true emergencies, and only when I/we expect to be contacted immediately. I/we will be responsible for payment of medical care expenses.

Discaimer Response

Do You agree with this Disclaimer*

Insurance Company Name*

Insurance Policy Number*

Child's Physician*

Physician's Phone Number*

Medical History

Asthma

Enter age at which child was first affected. Additional information can be provided in details section below.