Your Email Address: Child's First Name: Child's Last Name: Child's Date of Birth (MM/DD/YYYY):
Age (As of May 31, 2017): Grade Completed: Address: Home Phone:
Mother's Name: Mother's Cell Phone: Father's Name: Father's Cell Phone:
Emergency Contact Name: Emergency Contact Phone:
List ALL Food Allergies and other Medical Conditions
List ALL Persons allowed to pick up your child from VBS
What Church do you regularly attend?
By checking this box you give us permission to post your child's image on our facebook page. YES
