ShipWrecked Vacation Bible School _________Online Registration
Event Dates: June 18 - June 22, 2018
Event Times: 6:00 pm - 8:30 pm
Event Location: Mars United Presbyterian Church 232 Crowe Avenue, Mars, PA 16046
Contact Us: Mars UP (724) 625-1365 or St. Johns Lutheran Church (724) 625-1830
Child's First Name: *
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Child's Last Name: *
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Date of Birth: *
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Child's Age: *
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Last School Grade Completed: *
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Name of Parent(s) / Guardian (s): *
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Street Address: *
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City: *
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State: *
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ZIP: *
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Home Phone: *
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Parent/Caregiver Cellphone: *
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E-Mail *
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Home Church *
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Special Needs or Requests *
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Crew Assignment (for church use only)
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Allergies or other medical conditions *
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In case of emergency contact name *
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Phone *
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Relationship to child *
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