Your Child's Name (required)

Parent's / Guardian Name (required)

Physical address (required)

Mailing address if different

City (required)

Your State (required)
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Phone Number

Work Number

Cell Number

Your Email (required)

Child's Birthdate (required)

Last Grade completed (required)

---1st2nd3rd4th5th6th

Medical or other information we need to know (include any food allergies)

Emergency Contact

Phone Number

Emergency Contact 2

Phone Number 2

Dismissal Information: Who may pick up your child at the end of each VBS day?

Other Information: Does your child attend Sunday School? If so, where?

If your child is visiting our church, who is he or she a guest of?

May we have permission to photograph your child?
YesNo

May we have permission to use your child's photograph for the purpose of promotion?
YesNo

Any addition information you would like to provide