LCC VBS 2026

Child's Information

Name

Gender

Male Female

Grade

1st 2nd 3rd 4th 5th

School

Allergies

Any special information we should know about your child:

Parent/Guardian Info:

Parent/Guardian Name:

Parent/Guardian Phone

Parent/Guardian Email

This address will receive a confirmation email

Child lives with:

Address

What church do you attend?

Emergency Contact

Please provide two emergency contacts that can be reached at anytime.

Name

Phone

Name

Phone

Follow the link below to fill out your 2026 medical release form. PLEASE RETURN TO THIS PAGE once you have submitted your release form and complete your registration!

https://waiver.smartwaiver.com/w/4pzssei1pmtg1y5npgpbaw/web/

Registration is not complete UNLESS the medical release form is filled out.

I have filled out the medical release form for my child.

Yes

I/we understand that my child may be photographed while participating in the activities of Little Country Church. I/we give permission for a recognizable image of my child to be posted on the Little Country Church websites, bulletin boards, LCC Facebook groups, or used in promotional materials. I understand that the Little Country Church will not include my child’s last name or any identifying information. I understand that a non-recognizable image, such as a group picture, may be posted as well.

Yes No

Payment

Payment $45

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

LCC VBS 2026

Description

Please Fix the Following