Lakeshore Community Church VBS Registration Form
LCC "Wild West" 2019 VBS Registration Form
Email address *
Information
Child's First Name: *
Your answer
Child's Last Name: *
Your answer
Gender: *
Required
Age *
Date of Birth
MM
/
DD
/
YYYY
Name of Guardian(s): *
Your answer
Cell/Work Phone: *
Your answer
Secondary Contact Person *
Your answer
Cell/Work Phone: *
Your answer
Address: *
Your answer
City *
Your answer
Postal Code *
Your answer
Emergency Information
Emergency Contact Information *
Required
Phone Number *
Your answer
Allergies or other Medical Conditions *
Required
If Yes, describe
Your answer
Is Child bring medication to the program *
Required
If yes, name of medication(s): *
Your answer
Family Physician *
Your answer
Phone Number: *
Your answer
OHIP #: *
Your answer
General Information
Can your child have his / her photos taken during activities *
Required
Will your child be picked up? *
Required
If Yes, by whom? (List first and last names) *
Required
Signature (At time of Drop Off)
Your answer
Additional Information about your child
Your answer
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