Registration Form

Please complete all required fields and as many optional fields as possible then press the send button at the bottom of this form. Please complete one form per child/youth. Thanks!!!

* Required Fields

*Child's Name:
*Parent/Guardian Name:
*Physical Address:
Mailing Address (if different):
*City:
*State:
*Zip Code:
Home Phone:
*Cell Phone:
Work Phone:
Email Address:
*Birth Date (for preschoolers) or last grade completed in school:
*Medical or other information we need to know. (Please include any food allergies.):
*Emergency Contact Name:
*Emergency Contact Phone Number:
2nd Emergency Contact Name:
2nd Emergency Contact Number:
*Who may pick up your child at the end of each VBS night?:
*Will we need to pick up and bring home your child? If yes, you will be contacted to make arrangements.:	Yes No
Do you attend Sunday School? If so where?:
If you are visiting our church, who are you a guest of?:
May we have permission to photograph your child?:	Yes No
*May we have permission to use your child's photograph in church publications or on the church website for the purpose of promotion?:	Yes No
*Authentication:
*4 + 9 =	Enter the correct answer to the math question.
Please click the Send button only once.

Ralston Baptist Church

Pastor: Bro. Kerry Shopher

Registration Form