Completed 6th Grade

Enrollment Fee

Participant Information

Last Name^*

First Name^*

Gender^*

Male
Female

DOB (MM/DD/YYYY)^*

Birth Date (mm/dd/yyyy)

Choose from calendar first Year, then Month, then Day

Allergies, Medical & Special Needs (please enter "N/A" if none)^*

Home Address

Address Line 1 ^*

Address Line 2

City ^*

State or Region ^*

Country

Zip ^*

Participant T-Shirt Size

ATTENTION: Your selection of the T-shirt size is FINAL! No exchanges can be made because all VBS T-shirts are pre-ordered. So, please select carefully.

T-Shirt Size Selection^*

T-Shirt Size

Parent/Guardian 1 - Information

Last Name^*

First Name^*

Mobile Number^*

000-000-0000

Email Address (Primary)^*

PLEASE ENTER EMAIL CAREFULLY. This address will be the only one to receive all VBS email communication.

Parent/Guardian 2 - Information

Last Name

First Name

Mobile Number

000-000-0000

Secondary Email

Emergency Contact 1

Last Name^*

First Name^*

Mobile Number^*

000-000-0000

Emergency Contact 2

Last Name

First Name

Mobile Number

000-000-0000

Parent Mandatory Information

Do you attend church?^*

Yes, Atlanta Chinese Christian Church North (ACCCN)
Yes, other church
No

Would you like to volunteer?^*

Parental KidCheck profile Email account with ACCCN^*

KidCheck Profile Email Account

Parental PayPal Email account on VBS enrollment payment^*

PayPal Email Account on VBS Enrollment Payment

Photograph/Video and Medical Release^*

I am aware that photographs or video may be taken of my child during VBS activities by ACCCN staff members and/or volunteers. I give ACCCN and its representatives permission to use photographs or video that include my child in any and all media products for promotion, art, advertising, editorial or other purpose. This may include but is not limited to newsletters both print and email, posters, brochures, ads, post cards and web pages. 

I understand that all VBS teachers and administrative personnel at ACCCN are volunteers. Accordingly, on behalf myself, my child identified above, and our family, I hereby release all claims against ACCCN arising out of any accident (including any cause by negligence) involving the child. 

In the event of an emergency, if I cannot be reached, I give my permission to ACCCN to acquire medical attention if necessary. I accept the responsibility of my child for possible injury or illness encountered while involving in activities provided by ACCCN VBS on church property. I will not request for refunds if my child is absent due to such injury or illness. 

Please select yes to accept the waiver. If you choose NOT to accept this waiver, your child will be unable to attend VBS.

I Agree

Scroll and Read "Photograph/Video and Medical Release" Terms & Conditions Before Click "I agree" to accept the waiver

Parent's Electronic Signature^*

Parent's Electronic Signature

Select a payment method^*