Register for VCS We invite all of God’s children, ages four—5th grade, to this year’s VCS! If you have any questions, please contact Gloria Knopp at 412.441.3800 x122 or GloriaK@coh.net. VCS Registration Form Step 1 of 4 25% Student InformationStudent's Name* First Last Student's Age as of June 24, 2024* Student's Birth Date* Month Day Year Student's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Grade Completed as of June 2024*Has not yet started schoolPreschoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Student's Gender Student's Preferred Pronouns(she, he, they, etc.) Does your child have any food or environmental allergies?If so, please list them. Has your child received the COVID-19 vaccine?* Yes No Does your child have any special needs?If so, please list them. Will your child need to take medicine during their day with us? If so, please list the name of the medication and dosage.If so, please list them. Note About Preschool-Age ChildrenVCS Preschool is for children age 4 (must be 4 by June 24, 2024) to age five who have not completed Kindergarten. All preschoolers must be toilet-trained. Has your preschooler ever attended daycare/camp/preschool before? Yes No Parent(s)/Legal Guardian(s) of StudentParent/Guardian (1)* First Last Parent/Guardian (1) Home or Cell Phone NumberParent/Guardian (1) Work Phone NumberParent/Guardian (1) Email Address Address of Parent/Guardian (1) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian (2) First Last Parent/Guardian (2) Home or Cell Phone NumberParent/Guardian (2) Work Phone NumberParent/Guardian (2) Email Address Address of Parent/Guardian (2) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactPlease fill in all contact information.Emergency Contact Person* First Last Relationship to Student* Cell PhoneHome PhoneWork PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pick-Up Authorization*Please list everyone who is authorized to pick up your child: Photo Release AuthorizationPhotos are sometimes taken and used in the promotion of our ministries.Photo Consent I give East Liberty Presbyterian Church permission to use photos of the student listed on this form and to put the finished photos to any use (newsletter, bulletin boards, website) without limitations or reservation.Name of Person Completing this Form* First Last Help Us Get To Know You BetterWhat's the name of your home church? Are you looking for a home church? Yes No How did you hear about ELPC?Through a friendWebsiteMailing from ELPCAttended in a previous yearAdvertising sign about VCS outside of the churchOtherCAPTCHA