2010 VBS Registration

Operation Space	VBS August 2-6, 2010
	9:00am-Noon
	Children Ages 3 (by September 1)
	through Grade 5 (going into)
	Please complete one form per child
Instructions: Please fill out the form below and click the "Send" button at the bottom of the form. The fields with a red "*" are required fields.
Alternatively, you can download the Microsoft Word or Adobe PDF form and email or turn it in to the Church office

Child’s name:*

2010/2011 Grade:*

Birthdate/Year:*

Age:*

Parents’ Names/Guardian:*

Address:*

Home Phone:*

Cell Phone:

Emergency contact person:*

Emerg. contact relationship to student:

Emerg. contact Home Phone:*

Emerg. contact Alt. Phone:

Food allergies:*

Yes	(list)
No

Medical Concerns:*

Yes	(explain)
No

Family Doctor:*

Doctor's Phone:*

Siblings Attending VBS (names and ages):

Church Affiliation:

Church Membership at:

People who may pick up child:*

Transportation needed?

Yes

Attendance:

I hereby grant the VBS leaders permission to photograph/film the minor designated above for any lawful purpose associated with this VBS program.