Vacation Bible School Registration

July 12 - 16 2010

9 A.M. TO NOON

(Make sure you use the "tab" button between fields.

"Return/Enter" will submit the form before you are finished.)

Child's Name

Date of Birth Age

Last School grade completed

Child's Name

Date of Birth Age

Last School grade completed

Child's Name

Date of Birth Age

Last School grade completed

Parent/Guardian Name

Address

Email Address

Phone Numbers

Home Cell Work

Church Normally Attended Please select the church your family normally attends First Baptist Church of New Baden New Baden UMC St. Georges Catholic Church Zion UCC Other

       If Other, Please specify: 

Allergies/Medical Information/Other

Emergency Contacts

Name Phone

Name Phone

Dismissal Information

Name of person(s) who may pick up this child from VBS each day