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Student Name *
Grade Entering in September 2023
Name of Parent(s) *
Address
City
State
Zipcode
Home Telephone *
Parent/Caregiver's cell phone *
Email
Home Church
Name of friend he/she would like to be paired with
allergies or medical conditions (if none put N/A) *
In case of emergency contact:
emergency contact phone:
emergency contact relationship to child
Lighthouse Alliance Community Church/VBS has my permission to use my child's photograph publicly in VBS materials. I understand the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to my by reason of such use.
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