134 Abney Road, Cochran, GA 31014 mcbccochran@gmail.com 478-934-0810

VBS 2023

Child's Name*
First Last
Child's shirt size*
Parent/Guardian Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Parent/Guardian Cell Phone*
Parent/Guardian Work Phone
Parent/Guardian Email*
Child's Birthdate*
Date Format: MM slash DD slash YYYY
What grade will your child complete at the end of this school year?*
Medical Information including any Food Allergies
Emergency Contact other than listed above*
First Last
Emergency Contact Phone Number*
Authorized person to pick up child if parent/guardian or emergency contact are unavailable?*
First Last
May we have permission to photograph your child?*
- Yes
- No
May we have permission to use your child's photograph for the purpose of a VBS slideshow?*
- Yes
- No