VBS Registration Form
June 20-24, 2011
12:00 - 2:30 p.m.
Ages 5-11

Name:	*
Date of birth:	*
Grade in fall of 2011:	*
Street address:	*
City:	*
State:	*
ZIP:	*
Parent/Guardian:	*
Home telephone:	*
Email address:
In case of emergency, contact:	*
Relationship to child:	*
Phone:	*
Child may be picked up by:
Please place my child with:
Home church:
Allergies:	Yes   No
If yes, please list:
Medical concerns:	Yes   No
If yes, explain:
Attending Sports Camp (for grades 3-9):	Yes   No
(All children attending both VBS and Sports Camp will be provided lunch in between)
T-shirt size:	Youth XS   S   M   L Adult S
(T-shirt availability guaranteed only if you register by June 1st)
Enter text from verification image:
* Indicates requires fields