2017 VBS Registration Form
(one per child)
July 24-28. 9 am-noon
Child's Name
Your answer
Child's Age
Date of Birth
MM
/
DD
/
YYYY
Raising Grade Level
Name of parent(s)
Your answer
Street Address
Your answer
City
Your answer
Zip
Your answer
Home Phone
Your answer
Cell Phone(s)
Your answer
Home Email Address
Your answer
Home Church
Your answer
Allergies or other medial conditions
Your answer
ICE
In Case of Emergency Contact Person
Your answer
ICE
Phone
Your answer
ICE
Relationship to Child
Your answer
Name of friend(s) your child would like to be with at VBS
First and last name separated by commas
Your answer
Other Adults authorized to pick up your child
Only parents and/or anyone mentioned here will be allowed to pick up your child
Your answer
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