Registration and Special Needs Survey

Childs Nickname

Childs Age

Parent/Guardians Email Address

Parent/Guardians Cell Phone #

Childs Date of Birth

Name of Parents/Guardians

Street Address

City

State

Country

Zip

Custodial Arrangement (if applicable)

Allergies or other medical conditions (i.e. diabetes)

In case of emergency, contact:

Emergency Contact #

Emergency Contacts relationship to child?

I give permission to call 911 in case of emergency

Yes

I understand photographs will be taken during VBS.

Yes

Parent/Guardians Signature

Special Needs Survey - My child has the following educational label or medical diagnosis.

My childs primary means of communication is.

Additional information concerning my child's allergies or food sensitivities.

My child's favorite activities and interests are.

My child avoids doing or becomes easily frustrated with the following activities.

If my child becomes overwhelmed or frustrated they will respond best to.

My child's strengths are.

My child needs help with.

What suggestions do you have that may help us create the best possible experience for your child?

What information would you like us to share with other children at VBS that will help them better know, accept, and understand you child?

Vacation Bible School 2025

Jul 14, 2025, 6:00 PM MDT – Jul 18, 2025, 8:00 PM MDTPSDA Outreach and Education Center