* Child's Name:     Nickname / preferred name to be called:

* Parent / Guardian Name:

* Address:

* Home Phone:    Cell Phone:

* E-mail Address:

* Age:    * Date of Birth:  * Gender: Male Female

* Last School Grade Completed:

Siblings:

Home Faith Community (if any):

In case of emergency, please contact (when parent cannot be reached)

* Name:

* Telephone:    Cell Phone:

* Relationship to child:

Please list allergies or other medical needs:

Person responsible for picking up this child at the end of each VBS day:

* Name:

* Telephone:    Cell Phone:

Tell us anything special you'd like us to know about your child:

Please indicate if you would like to volunteer to help at VBS: Yes No   Days Available:

* This information is required in order to register.