Child's First Name (*)

Please type your full name.
Child's Last Name (*)

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Grade going into this year (2011-2012) (*)
Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade
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Child's Birthday (*)

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Parent/Guardian First Name (*)

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Parent/Guardian Last Name (*)

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Parent Guardian E-mail (*)

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Address (*)

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Address Line 2

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City (*)

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State (*)

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Zip Code (*)

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Emergency cell phone number during VBS hours (*)

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Allergies or Medical Needs

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(If your child has severe food allergies please send a snack each day)

T-Shirt Size (*)
S(6-8)M(10-12)L(14-16)XL(18-20)
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My child would like to be in a group with his/her friends. List up to 3 friends:

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We will try our best to accommodate friend requests as much as possible.

Additional Comments

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I will pay my registration fees through (*)
paypal online
by sending a check

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