Roar VBS Registration Form
For preschool-5th grade; July 21-24; Meal starting at 5:15 pm and program 6-8 pm. Program will be limited to 60 participants. For any questions call (309)452-2277 or email
Name(s) and Age(s) *
Last School Grade(s) Completed *
Street Address *
Date(s) of Birth *
Home Telephone *
Parent/Guardian Name *
Parent/Guardian Cell phone *
Home Email Address *
Allergies or other medical condition *
In Case of Emergency, Contact *
Phone Number *
Relationship to child/children *
Additional Comments or Concerns
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