VBS Registration Form 2010

Name:

Street Address:

City:

State:

Zip Code:

Home Phone:

Home E-mail Address:

Age:

Date of Birth:

Last School Grade Completed:

Home Church:

Contact Information

Mother:

Work:

Cell:

Father:

Work:

Cell:

Other:

Name:

Phone Number:

Allergies and Other Medical Conditions:

Medications:

Special Instructions:

Due to the nature of our program children are grouped in multi-aged groups

and there is no guarantee that siblings or friends can be placed together.


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