2018 Mill Creek VBS Registration
Child's Last Name *
Your answer
Child's First Name *
Your answer
Child's Birthday *
MM
/
DD
/
YYYY
Last Grade Child Completed *
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Father/Guardian Name *
Your answer
Father/Guardian Phone # *
Your answer
Father/Guardian Email
Your answer
Mother/Guardian Name *
Your answer
Mother/Guardian Phone # *
Your answer
Mother Guardian Email
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone # *
Your answer
Secondary Emergency Contact Name
Your answer
Secondary Emergency Phone #
Your answer
Please list the names of all the people to whom we can release your child. *
Your answer
Please identify any allergies, important medical information, or special needs for which the staff at Mill Creek should be aware.
Your answer
May we take pictures and/or video of your child *
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