Vacation Bible School 2017
Your child is invited to Vacation Bible School at

St. Stephen Lutheran Church & School
320 Moorpark Way, Mountain View

July 24-28, 2017 (Monday – Friday) from 9 am – 11:30 am
FREE (donations are welcome)
For children entering: Grades Pre-K through 8th

Questions? Please call 650-204-9751

1st Child
Child's Name
Your answer
Grade Entering
Sex
Date of Birth
Your answer
2nd Child (if applicable)
Child's Name
2nd Child
Your answer
Grade Entering
2nd Child
Sex
2nd Child
Date of Birth
2nd Child
Your answer
3rd Child (if applicable)
Child's Name
3rd Child
Your answer
Grade Entering
3rd Child
Sex
3rd Child
Date of Birth
3rd Child
Your answer
General Information
Home Phone
Your answer
Secondary Phone Numbers (work and/or cell)
Your answer
Are there any days your child is NOT attending?
Address
Your answer
City
Your answer
Zip
Your answer
Mother's or Guardian's Name
Your answer
Father's or Guardian's Name
Your answer
Are you available to assist with snacks or crafts?
If yes, which days?
Your answer
If my child needs to go home because of illness or accident, and I cannot be reached, call:
Please list two contacts including a phone number and address for both
Your answer
Is your child taking any medication?
If yes, please explain
Your answer
Health problems or allergies?
Your answer
Emergency Contact Information
In case of emergency, I hereby give my consent for treatment to be given by:
Doctor
Your answer
Address
Your answer
Hospital
Your answer
Phone
Your answer
Insurance Provider
Your answer
Medical #
Your answer
Parent or Guardian / Date
Please give name and date to indicate consent for treatment
Your answer
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