Student's Name *

First Name

Last Name

Parent/Family/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

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Work Phone

(###)

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Date of Birth *

MM

DD

YYYY

Emergency Contact #1 Name *

First Name

Last Name

Emergency Contact #1 Phone *

(###)

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Emergency Contact #2 Name *

First Name

Last Name

Emergency Contact #2 Phone *

(###)

###

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Photo Release *

Please select one:

Newton Zion Reformed Church/VBS has my permission to use my child's photograph publicly in VBS materials. I understand the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Please refrain from using my child's photograph.