VBS 2019 Registration
St. Mary's Catholic Church
1518 Parker St.
North Little Rock, AR 72114
Phone: (501) 374-5237
July 15th - July 19th
9:00 am - 12:00 pm
For children Grades K -5th
Child's Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Gender:
Last grade completed in school:
Your answer
Name of parent(s):
Your answer
Street address:
Your answer
City:
Your answer
State:
Zip
Your answer
Cell phone:
Your answer
Work phone:
Your answer
Home phone:
Your answer
Email address:
Your answer
Home church:
Your answer
Allergies:
Your answer
Medical conditions/ concerns:
Your answer
Emergency contact:
Your answer
Emergency contact phone:
Your answer
Relationship to child:
Your answer
Siblings attending VBS (names and ages)
Your answer
I hereby grant VBS leaders permission to photograph/ film the minor(s) designated above in any manner or form for any lawful purpose associated with this VBS program.
For Questions or Concerns please contact Angela Owen, mrs.owennlrca@gmail.com
Each child needs to be registered separately.
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