This form will enable you to register up to 4 children.

* Indicates Required Fields 

*This Registration is for:

  VBS

*Child's Name (1)

Child's Name (2)

Child's Name (3)

Child's Name (4)

*Parent's/Guardian's Name

*Street Address

*City

*US State

*Zip Code

*Home or Work Phone

Cell Phone Number

Pager Number

*Email Address

*Last Grade Completed (Child 1)

Preschool Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade

Last Grade Completed (Child 2)

Preschool Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade

Last Grade Completed (Child 3)

Preschool Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade

Last Grade Completed (Child 4)

Preschool Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade

*T-Shirt Size (Child 1)

Extra Small Small Medium Large Extra Large

T-Shirt Size (Child 2)

Extra Small Small Medium Large Extra Large

T-Shirt Size (Child 3)

Extra Small Small Medium Large Extra Large

T-Shirt Size (Child 4)

Extra Small Small Medium Large Extra Large

Do you attend church?

Yes     No

If so, where?

*Medical or other information we need to know (Please include any food allergies) 

Medical or other information we need to know (Please include any food allergies) 

Medical or other information we need to know (Please include any food allergies) 

Medical or other information we need to know (Please include any food allergies) 

*Emergency Contact Name & Phone

Emergency Contact Name & Phone

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

Comments or Additional Information

How did you hear about our VBS?

Newspaper  Friend  Mailing
Door Hanger  Church Sign
Other (please specify)