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Vacation Bible School (VBS)

1Child Registration

2Parent/Guardian's Information

3Media/Liability Release

Number of children to register

1

2

3

4

5

6

7

Please select the number of children you would like to register to participate in VBS 2025

First Child

First Child Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Grade starting in the fall(Required)

Allergies/Medical Needs?

No

Yes

Allergy/Medical details

Second Child

Second Child Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Grade starting in the fall(Required)

Allergies/Medical Needs?

No

Yes

Allergy/Medical details

Third Child

Third Child Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Grade starting in the fall(Required)

Allergies/Medical Needs?

No

Yes

Allergy/Medical details

Fourth Child

Forth Child Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Grade starting in the fall(Required)

Allergies/Medical Needs?

No

Yes

Allergy/Medical details

Fifth Child

Fifth Child Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Grade starting in the fall(Required)

Allergies/Medical Needs?

No

Yes

Allergy/Medical details

Sixth Child

Sixth Child Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Grade starting in the fall(Required)

Allergies/Medical Needs?

No

Yes

Allergy/Medical details

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Primary Email(Required)

Home Church

How did you hear about Jerusalem Chapel?

Authorized pick up

In the event that I, the parent/guardian, am unable to pick up my child, I authorize the following adults listed below to pick up him/her from Jerusalem Chapel VBS. I understand this must be an adult (no siblings may pick up my child) and ONLY the people listed will be allowed to pick up my child. Only prior written agreed-upon authorization will be accepted.

Authroized Pickup Person #1

Name(Required)

First Last

Phone(Required)

Relationship to the child(Required)

Authroized Pickup Person #2

Name

First Last

Phone

Relationship to the child

Not Authorized Pick Up Person (Names)

Hospital

Preffered Hospital in case of emergency?(Required)

Doctor(Required)

Doctor Phone #

Health Insurance Company(Required)

Policy #(Required)

Release information

In submitting this form, I certify that the above information is correct and give permission for the use of photographs including my son/daughter to be used in church publicity. On behalf of my child participant, I assume all risk of personal injury, damage, and expense as the result of participation in the Jerusalem Chapel VBS program. In case of emergency, I give my permission to seek medical treatment for my child.

Consent(Required)

I agree to the medical release form

Please understand, we request this information because of our commitment to the safety and well-being of each child attending Jerusalem Chapel VBS.

Comments

This field is for validation purposes and should be left unchanged.

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Weekly Schedule

Wednesday
5:30 pm	Fellowship Meal
6:15 pm	Awana
6:30 pm	Worship-based Prayer
Sunday Morning
8:45 am	Sunday School
10:00 am	Worship Service

Contact Information

935 Jerusalem Chapel Rd
Churchville, VA 24421
^{Get Directions}

(540) 337 6411
office@jerusalemchapel.com

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