"Shipwrecked, Rescued by Jesus!"
Vacation Bible School
Place: St. Jacob Lutheran Church
Date: June 11-15, 2018
Time: 9:00 a.m. – 11:30 a.m.
Ages: age 3 through just completed 6th grade (must be potty-trained)

To register, complete the form below (1 per child) for any questions please contact Kara Kipp, VBS Coordinator, at karalkipp@gmail.com or call the church at 937-394-4421.

Child's First Name *
Your answer
Child's Last Name *
Your answer
Birth Date *
MM
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DD
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YYYY
Last Grade Completed? *
Known Allergies or other medical concerns?
Your answer
Parent's Name *
Your answer
Parent's Email *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Emergency Contact & Phone *
Your answer
Doctor Name & Phone *
Your answer
Brothers & Sisters attending VBS
Your answer
Mailing Address *
Your answer
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