Child's Name:    Date of Birth:    Grade entering 2010/2011:  

Parents/Guardian:    Home Phone Number: 

Address:      City:     Zip:     

Parent/Caregiver Cell Phone:     (In the event of an emergency we will call this number first)

Email: 

In addition to the above listed parent/caregiver, please list anyone else who is authorized to pick up your child:

Name:     Phone:   Relationship: 

Name:     Phone:   Relationship: 

Name:     Phone:   Relationship: 

Emergency Contact:  Name:     Phone: 

Allergies or other medical conditions: 

Family Dr./Hospital preference: 

Home Church:    Would you like a staff person to call? 

Would you be willing to volunteer to help with VBS this year? 

Comments for VBS Staff: 

Prefer to print a form and bring it to the church?

Click here.