VBS Registration
June 18-20
6-8:30 p.m.

Child Name

One Registration Per Child

First Name

Last Name

Age

Date of Birth

Last School Grade Completed

Parent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Email

Home Church

Allergies or Other Medical Conditions

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Relationship to Child