Name of Child

Grade Entering

Age

Birthdate

Allergies or other medical conditions

List a friend you would like to be grouped with

Name of Child

Grade Entering

Age

Birthdate

Allergies or other medical conditions

List a friend you would like to be grouped with

Name of Parent(s) or Guardian(s)

Email Address

Home Phone #

Cell Phone #

Call this # in emergency

Can you be a VBS volunteer? Can you be a VBS volunteer? Yes No

If YES, which day(s)? If YES, which day(s)? M T W Th

If yes, what position?

Other emergency contact name

Other emergency contact phone #

Other emergency contact relationship to child