Child's Name

Child's Age

Child's Birth Date

Child's Grade

Parent/Guardian Name(s)

Home Phone

Work Phone

Mobile Phone

Email

Preferred Contact Method Preferred Contact Method Home Phone Work Phone Mobile Phone Email

Emergency Contact 1

Phone

Emergency Contact 2

Phone

Doctor

Phone

Allergies or Special Needs

Name of person authorized to pick up your child at the end of each VBS program:

Relationship

Name of person authorized to pick up your child at the end of each VBS program:

Relationship

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Date