Breaker Rock Beach Registration

Name of Child *

First Name

Last Name

Name of Parent/Guardian *

First Name

Last Name

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Person *

(Different from above)

First Name

Last Name

Phone *

(###)

###

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Do we have permission to photograph your child? *

(During VBS we will take pictures to make a short video for the party at the end. Some photos may be used for promotional purposes)

Yes

No