VBS Registration June 17-20, 2019
5:30PM-8:00PM held at First Congregational UCC
255 W 10th St. Dubuque, IA 52001
563-582-3648
Child's name *
Your answer
Child's age *
Your answer
Child's date of birth *
MM
/
DD
/
YYYY
Grade last completed *
Your answer
Allergies or other medical conditions *
Your answer
Name of parent(s) or guardian *
Your answer
Home email address *
Your answer
Home address *
Your answer
Parent or guardian cell number *
Your answer
Home phone number
Your answer
Best number to contact in case of emergency *
Your answer
Relationship to child *
Your answer
Home church *
For staff use only- Classroom Planet
Your answer
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