Registration Form

Child’s Name:_________________________________________________ 

Street Address:________________________________________________ 

City:  ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­________________________ State:______________ ZIP_________ 

Home telephone: (_____) __________     Cell phone: (_____) ___________ 

Home e-mail address:__________________________________________ 

Date of Birth:_________________            Age:________________________ 

Last school grade completed:____________________________________ 

Mother’s Name:_______________________________________________ 

Father’s Name:_______________________________________________ 

Emergency contact:____________________________________________ 

Others allowed to pick up child:___________________________________ 

Allergies or other medical conditions:______________________________ 

Home church:________________________________________________ 

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

How did you hear about our VBS?:             Word of mouth_____ 

                                                                         Banner___________ 

                                                                         Newspaper________ 

                                                                         Letter____________ 

Door hanger_______