Please Complete.

Child 1:

Child 2:

Child 3:

Child 4:

(Max 4 children per e-mail)

Complete Address:

Home Phone:

Cell Phone

Parent/guardians Name:

Allergies/Medical Information:

(Please specify which child if multiple children are listed on this form)

Emergency Contact:


Child 1: Birthdate/S:
- Age: - Grade Completed:

Child 2: Birthdate/S:
- Age: - Grade Completed:

Child 3: Birthdate/S:
- Age: - Grade Completed:

Child 4: Birthdate/S:
- Age: - Grade Completed:

Child's/ Children's Home Church, if applicable

In consideration of Jeffersonton Baptist Church (JBC) allowing your child to participate in Over The Moat VBS, I agree to hold harmless JBC, it’s pastors, directors, employees, volunteers and teachers from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the child and/or the undersigned while involved in VB.