2024 Breaker Rock Beach Vacation Bible School
Lake Placid Baptist Church, Lake Placid NY

Monday, June 24 through Friday, June 28
9 - 11:30 AM
4-year-olds through 5th grade (based on age or last grade completed)
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Parent or Guardian Last Name *
Parent or Guardian First Name* *
Best Phone Number for Parent or Guardian *
Email Address *
Mailing Address *
City *
State *
Zip Code *
Child's Last Name (if different from parent or guardian listed above)
Child's First Name *
Child's Date of Birth *
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Last Grade Completed *
If you have multiple children participating, please list below the remaining children's first names, birthdates, and last grade completed. (If any child has a different last name from the parent/guardian listed above, please also give the child's last name).
Does any child registered on this form have any medical concerns or food allergies? *
If you answered yes above, please list all medical and/or food allergy information below (if multiple children are listed on this registration, please specify which child has the allergy).
Emergency Contacts / Permissions                   *
Please list adults (other than parent/guardian listed above) who have permission to pick up your child at the end of each day and make decisions for your child in case of an emergency . *Note: they must have pick-up tag or show ID for child to be released to them at the end of the day.
Every year we like to give out copies of the VBS music for the children to have at home throughout the year. Please list your preference below.  *
Parent or Guardian Signature *
Today's Date *
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