VBS Registration 2018
For: kids ages 3 through grade 6
Date: August 6 - 10
Time: 5:30 - 7:45 PM
Location: Cross Roads Community Church, 271 Main Street, Leechburg, PA
Contact us at 724-845-1901 or church@crcpc.org
Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Completed Grade Level *
Address *
Your answer
Parent/Guardian Name *
Your answer
Phone Number *
Your answer
Emergency Phone Number *
Your answer
Email Address
Your answer
Emergency Contact *
Your answer
Alternate Contact Phone Number *
Your answer
Medical Issues/Concerns
Your answer
Name of Person Picking up Child(ren) *
Your answer
Name of Home Church *
Your answer
I give my permission for my child's/children's picture to be used for publicity purposes.
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