Parent/Grandparent/Guardian:

Street Address:

City:	Zip:

Home Phone:	Cell Phone:	Email:

Preferred Contact Method:

Select One... Home Phone Cell Phone Email

In case of emergency, contact:	Phone Number:

Church Membership:

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Home Church:

Will parent(s) be helping in other areas of VBS?:

Yes No

If yes, where?:

Child Pick-Up Authorization:

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	Person(s) with permission to pick up child/children:
#1
#2
#3

Please indicate a Pick Up Password:

NOTE: The person picking up your child must know the password in order for us to release your child into their custody.

Attending Children:

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Child must have been born before 10/1/2003 to attend VBS.

Child #1
Name	Birthdate (mm/dd/yyyy)	Grade Completed
		N/A Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Medical Notes

Child #2
Name	Birthdate (mm/dd/yyyy)	Grade Completed
		N/A Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Medical Notes

Child #3
Name	Birthdate (mm/dd/yyyy)	Grade Completed
		N/A Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Medical Notes

Child #4
Name	Birthdate (mm/dd/yyyy)	Grade Completed
		N/A Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Medical Notes

Child #5
Name	Birthdate (mm/dd/yyyy)	Grade Completed
		N/A Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Medical Notes

Child #6
Name	Birthdate (mm/dd/yyyy)	Grade Completed
		N/A Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Medical Notes