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Participant Registration

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Registro en Español

Chantilly Bible Church

Location

4390 Pleasant Valley Rd

Chantilly, VA 20151-1342

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Contact Rita Barillas:

703-263-1188

rita.barillas@chantillybible.org

First, Tell Us About Yourself:

Parent Information

First Name

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Last Name

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Contact Phone 1

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Spouse First name (if applicable)

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Spouse Last name (if applicable)

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Spouse's email

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Spouse's contact phone

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Address 1

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City

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ZIP/Postal Code

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Alternate Emergency Contact Information

Emergency contact name - DO NOT put your name or spouse's name here. This is an alternate contact when we cannot reach a parent. We will always try to reach parents first.

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Emergency Contact Relationship

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Emergency Contact Phone

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Safety Information

Name of any individual(s) who MAY NOT pick up your child

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Permission for Emergency Care and Medical Release

I, the undersigned parent/guardian, do hereby grant permission for my child(ren), named below, to receive the proper medical treatment in the event that he/she may sustain injury or illness during the period of VBS. I hereby authorize the VBS staff to obtain or provide medical treatment for my child(ren) for such injury or illness during VBS. The VBS staff has my permission in an emergency to take my child(ren), at my expense, to the hospital emergency room deemed appropriate by the rescue squad or the adult advisor(s). The hospital and its medical staff have my authorization to provide treatment, which a physician deems necessary, including anesthesia, for the well-being of my child(ren). I understand every effort will be made to contact me in such a situation.

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Security Agreement

Each family participating in VBS will receive three security cards that show the family identification number. The VBS staff will release a child to anyone who presents a security card with a family ID that matches the child’s family ID. It is imperative therefore that parents and guardians protect the cards and give them only to people authorized to pick up their children. The VBS staff will not release a child to anyone that does not have the matching security card, except for the parent or guardian upon presentation of picture identification. I understand the security mechanism being used to protect my child and agree to fulfill my responsibility of protecting the security cards, presenting picture identification when requested, and informing the VBS staff of anyone who may not pick up the child.

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Image Notification

CBC may use photos and videos taken at events in our publications, website and services, but will not identify children in these productions. Images can be taken down at a parent's request.

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Optional questions to help us understand who comes to VBS

Home Church Affiliation

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How did you hear about our VBS?

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Click here for your FREE Friends With God Kids Activity Pack

By checking the box you will be emailed your Free Friends With God Kids Activity Pack.

You are also agreeing to receive emails about family resources from Lifetree. You can unsubscribe at any time. We value your privacy. Your information will not be shared with a third party. Lifetree is a division of Group Publishing, the creators of Group VBS and other faith-building resources. Click to learn more about Lifetree.

Tell Us About Your Participant

Registration is open for children 5 years old by October 1, 2026 through 3rd grade (completed this year). Nursery - Preschool child registration is available for those who attend CBC and are volunteering in VBS.

First Name

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Last Name

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Grade Leaving Choices

For children ages 0-4 years old (not 5 years old by October 1, 2026) AND the parent is a volunteer, choose NURSERY.

For children who will be 5 years old by October 1, 2026, choose PRE-K.

For children who have completed Kindergarten - 3rd grade, choose the grade your child has completed.

Grade Leaving

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Gender

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Date Of Birth

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Does your child have allergies? If Yes, please provide additional information.

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We care for the success and safety of each child at VBS. Does your child have any special needs, learning disabilities, medical conditions or behavioral diagnosis we can prepare to support? If Yes, please provide additional information.

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Please list one or two friends that your child would like to be with. We cannot guarantee friends will be placed together, and we cannot make changes the week of VBS.

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Friend 1 First name

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Friend 1 Last Name

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Friend 2 First Name

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Friend 2 Last Name

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