Registration Form

June 22-26 | Registration form (one per child) for VBS June 22-26 6pm to 8pm

Child's name

*

Child's gender

*

Please select one option.

Male Female

Child's age

*

Please select one option.

3 4 5 6 7 8 9 10 11

Date of Birth m/d/y

*

Last school grade completed

*

Name of Parent

*

Address

*

Phone

*

Email

*

This address will receive a confirmation email

Home Church

*

Allergies, medical conditions, or special needs

In case of emergency, contact

*

Emergency contact phone

*

Relationship to child

*

Payment $5

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

June 22-26

Registration form (one per child) for VBS June 22-26 6pm to 8pm

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