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VBS 2017: Maker Fun Factory on Monday, June 12, 2017

Base Price: $0.00
This form must be filled out by the Parent/Guardian. Please list each child who will be attending VBS. Our VBS is for all children Kindergarten - 5th grades. This is the grade they will be in fall of 2017. Kindergarten is limited to the first 50 children.


Parent/Guardian Information

*Parent/Guardian First Name:
*Parent/Guardian Last Name:
*Address::
*City::
*Zip Code::
*Primary Phone (xxx-xxx-xxxx):
Alternate Phone (xxx-xxx-xxxx):
Name & phone number of anyone (other than you) authorized to sign your children in or out of VBS:
I am volunteering and need my child(ren) to be placed in the Nursery (ages 0-5). Please list child(ren)'s name and ages.

Registration Instructions


Child #1 is required in order to complete registration. Children 2 - 5 are optional. Be sure to scroll down and complete Medical Information.
*(1) Child's First Name
*(1) Child Last Name:
*(1)Age::
*(1)Birth Date MM/DD/YYYY:
*(1)Grade this Fall: 
(1)Place my child in the same group as (same grade only!):
(1)Food Allergy (provide own snack in plastic bag): 

Child 2

(2)Child's First Name:
(2)Child's Last Name:
(2)Age::
(2)Birth Date MM/DD/YYYY:
(2)Grade this Fall:
(2)Place my child in the same group as (same grade only!):
(2)Food Allergy (provide own snack in plastic bag):

Child 3


(3)Child's First Name:
(3)Child's Last Name:
(3)Age::
(3)Birth Date MM/DD/YYYY:
(3)Grade this Fall:
(3)Place my child in the same group as (same grade only!):
(3)Food Allergy (provide own snack in plastic bag):

Child 4


(4)Child's First Name:
(4)Child's Last Name:
(4)Age::
(4)Birth Date MM/DD/YYYY:
(4)Grade this Fall:
(4)Place my child in the same group as (same grade only!):
(4)Food Allergy (provide own snack in plastic bag):

Child 5


(5)Child's First Name:
(5)Child's Last Name:
(5)Age::
(5)Birth Date MM/DD/YYYY:
(5)Grade this Fall:
(5)Place my child in the same group as (same grade only!):
(5)Food Allergy (provide own snack in plastic bag):


Medical Information

*Parent(s) Employer:
*Work Phone #:
*Insurance Company's Name:
*Insurance Company's Phone #:
*Policy #:
*Group #:
*Name on Policy
Please list any medical conditions, special needs, and medications for which your child is presently being treated.  Include any instructions needed for these conditions.
Anyone with food allergies will need to provide their own snack for each day. Please put their snack in a zip lock bag with the child's name and give to leader.
*AUTHORIZATION TO CONSENT TO TREATMENT::
*Electronic Signature of Parent/Guardian
*Date MM/DD/YYYY: