VBX 2021
Please fill out this form and click submit.
PARENT INFORMATION
Parent Name
*
Parent Email
*
This address will receive a confirmation email
Parent Phone
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Additional Parent Name
Additional Parent Phone
Church Regularly Attend (if any)
YOUTH INFORMATION
List Youth Attending - Full Name, Birthdate, Grade Completed:
*
List any allergies/medical information (specify child):
EMERGENCY CONTACT INFORMATION
Emergency Contact (other than parent):
*
Emergency Contact Phone:
*
Relationship to Youth:
*
PERMISSIONS
I, the parent or legal guardian of the above named, allow him/her to attend VBX. I recognize the risk involved in activities and will not hold the Coventry Church of the Brethren, its staff or volunteers, responsible for any personal injury that might occur to my child while participating in this program. I authorize a staff member or volunteer from the church to seek and obtain such emergency or medical services for my child as deemed necessary at the time.
*
Please select one option.
I Agree
I Disagree
I give my permission for my child/children to appear on Coventry Church of the Brethren's website, Facebook page and/or other promotions.
*
Please select one option.
I Agree
I Disagree
Submit
Description
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