Email address:
Will Parent/Guardian be attending VBS with the child? Yes No
Child's Name: *
Child's Age: * Last Grade Completed: Pre k kindergarden 1 2 3 4 5 6 7 8 9 10 11 12 college N/A Date of Birth: *
Address: *
City: * State: * Zip: *
Phone: * Cell Phone:
In case of an emergency call * at *
Food Allergies:
Medical or other info we need to know:
People authorized to pick up child from VBS: *
Do you have a church home? Yes No
If so, where?