Jireh Church VBS Registration Form
REGISTRATION DATES - May 1, 2018 to June 16, 2018
Place:
OCM Jireh Church
55 Vanderburg Road
Marlboro, NJ 07746
Date:
July 9th, 2018 to July 13th, 2018
Time:
9:00 AM to 12:30 PM
Cost:
$40 per child (Please make check payable to OCM Jireh Church)
Registration deadline:
Please register by 06/16/18. Mail payment to Jireh Church at the above address.
REGISTRATION
Child's Name: *
Your answer
Gender: *
Date of Birth: *
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Grade in September: *
Your answer
Age: *
Your answer
Allergies or medical concerns: *
Special requests: *
CONTACT INFORMATION
Parent's Name (English and/or Chinese): *
Your answer
Address: *
Your answer
Home Phone: *
Your answer
Cell or Emergency Phone: *
Your answer
Parent's email: *
Your answer
Church you currently attend: *
Medical Insurance Name: *
Your answer
Medical Insurance ID *
Your answer
PARENTAL PERMISSIONS
If a parent will not be picking up your child(ren), please give the name of that person. *
I allow my children to play outside. *
Parent's signature: *
Your answer
Date: *
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If you would like to register more than one child, click "Submit another response" after submitting this form.
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