VBS Registration Form

Child's Name First Last
Parent/Guardian Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email
Home Phone - (###) - ### ####
Cell Number - (###) - ### ####
Work Number - (###) - ### ####
Age Information: Date of Birth
Last school grade completed
Home Church
Allergies/Medical Information/Other
Emergency Contact: First Last
Phone - (###) - ### ####
Emergency Contact, 2nd choice First Last
Phone - (###) - ### ####
Dismissal Information: Name of person(s) who may pickup this child from VBS: