Vacation Bible Camp 2019
June 17-21 9am-12pm
Email address *
Student Information
First Name *
Your answer
Last Name *
Your answer
Home Address *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Age *
T-Shirt Size *
Parent/Guardian Information
Name and Relationship *
Your answer
Address *
Your answer
Phone Number *
Your answer
Emergency Contact
Other than Parent/Guardian
Name and Relationship *
Your answer
Phone Number *
Your answer
Health Information
Allergies *
Your answer
Health Insurance Provider Name & Address *
Your answer
Doctor's Name and Phone Number *
Your answer
Dentist's Name and Phone Number
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Consent *
Required
Today's Date *
MM
/
DD
/
YYYY
Parent Name as Signature *
Your answer
Payment
Registration $35 (after June 1st $45)
Please make payment (cash, check or credit card) in the MSSE Office
Checks payable to "Mary Star Elementary"
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