LBC VBS 2017 Registration Form

Childs Name:

Child's Gender:

Child's Age:

Date of Birth:
Month Day Year

Last School Grade Completed:

Name of Parent(s):
1st Parent


2nd Parent

Street Address:

City:

State:

Zipcode:

Home Telephone:

Parent/Caregiver's Cell Phone:

Home Email Address:

Home Church:


Medical & Emergency Contact Section

Allegies or other medical conditions:

In case of emergency, contact:

Phone:

Relationship to child: