Pemberville Vacation Bible School Registration
June 17 - 21, 2019
9:00 am - 11:45 am

Ages: 4 years old by August 1, 2019 (and potty trained) through completed 5th grade

Bethlehem Lutheran Church
220 Cedar Street
Pemberville, OH 43450
419-287-4182

Please fill out one registration per child.

First Name *
of child
Your answer
Last Name *
of child
Your answer
Parent Name *
Your answer
Phone *
First one to call in an emergency. Please use 555-555-5555 format.
Your answer
Phone *
Another number to call in an emergency. Please use 555-555-5555 format.
Your answer
Email *
of parent
Your answer
Date of Birth *
of child. Use month/day/year format.
MM
/
DD
/
YYYY
Grade *
for the grade they just completed (2018-2019)
Home Congregation
If you don't have a home congregation, please put "none".
Your answer
Doctor Name *
Your answer
Doctor Phone *
Your answer
Preferred Hospital *
Your answer
Medical Information and Allergies *
List emergency information to be shared with VBS staff.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service