Vacation Bible School Form

Child Name *

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Last

Date & Year of Birth *

Grade child is entering in the fall. Registration is closed for grades 3-5. *

Parent/Guardian Name *

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Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Please list names of those allowed to pick up your child:

Please list any known allergies or put "none"

Does your child carry an Epi Pen?

If yes, please give instructions for usage below:

List any dietary restrictions:

List any activities your child should be restricted from:

If your child has a health issue, please give special instructions if any are needed (such as "my child uses an inhaler").

T-Shirt Size *

Digital Signature *

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Last

Vacation Bible School