Please provide the following contact information:

Name
Age:
Street Address
Address (cont.)
City
State
Zip Code
Home Phone
Cell Phone
E-mail
Date of Birth
Last school grade completed

In case of emergency, contact: 

Mother: 

Father: 

Other: 

Allergies or other medical conditions:

Name of a special friend your child might like to be with: 

 

If you are planning to join us for dinner before VBS,
please remember to complete the dinner registration form.