Child's Name *

First Name

Last Name

Child's Primary Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Parent/Family/Guardian Name *

First Name

Last Name

Parent's Cell Phone *

(###)

###

####

Parent's Work Phone

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

####

Photo Release Agreement *

New Haven UMC has my permission to use my child's photograph on social media, website, online publications, presentations, and other potential VBS promotions. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Agree

Disagree