Child's Name:

Check one: Boy Girl

Date of Birth: (Month, Day and Year)

Age:

Grade Entering In September 2008:

Name of Sibling(s) Also Attending VBS:

Mailing Address:

Street Address: (if different)

City:  Zip Code:

Parent Name(s):

Name of Parent On Site: (Required to be on site for children 3 or under)

Daytime Phone Number:

Emergency Contact Name & Daytime Phone Number:

Your Email Address:

Name of Home Church:

Please List Your Child's Allergies or Other Medical Conditions

I am the parent or guardian of this child: Yes No