VBS Registration Form

Child's Name *

Child's Birthday *

Last Grade Completed (as of July 2017) *

Medical Information

Parent's Information

Mother's Name *

Mother's Email *

Mother's Cell Phone*

Father's Name

Father's Email

Father's Cell Phone

Address *

City *

Zip *

Home Phone*

Emergency Contact

Name* -

Phone* -

Do you attend church? If so, where?

If you are visiting our church, who are you a guest of?

Dismissal Information

Who may pick up your child at the end of each VBS day?*