*VBS 2022 Registration*

ANTIOCH BAPTIST CHURCH VBS 2022 REGISTRATION
Date: June 20th-23rd * Time: 6:00 -7:45 PM
Location: Antioch Baptist Church, Mud Rd., Madison, VA
Email us for more information

* Indicates required field

Child's Name *

First

Last

Gender *

Male Female

DOB *

Age *

Grade in Fall 2022 *

Siblings Attending VBS *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent/Guardian Name *

First

Last

Email *

Phone Number during VBS Week *

Secondary Phone Number during VBS Week *

Emergency Contact *

Emergency Contact Phone Number *

Pediatrician Name *

First

Last

Pediatrician Phone Number *

Food Allergies *

Additional Information *

Member of: *

Antioch Other None

Photos will be taken in commemoration. Do we have permission to include your child in photographs? *

Yes No

Submit