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Image may contain: text
Childs Information
Child's Name: *
Birth Date: *
What grade is your child going to be in this fall?
 Age 4 or 5 & not going to school
 5 & in Kindergarten
 Kindergarten
 1st Grade
 2nd Grade
 3rd Grade
 4th Grade
 5th Grade
 6th Grade
Please list any food allergies your child has:


Are there any health/physical limitations?
Parent/Gaurdian Information
Parent/Gaurdian Firstname: *   Address: *
      City: *
    State:       Zip: *
Parent/Gaurdian Lastname: *
Parent/Gaurdian Email Address:  *    

Primary Phone Number:
*
  Select all that apply:
 Both the primary & secondary are cell phones
 Only the primary number is a cell phone
 Only the secondary number is a cell phone
 Neither are cell phones; 
Secondary Phone Number: 
Emergency Contact Information     Your Special Pick-up List
Emergency Contact Name:  *   List anyone who CAN pick up your child:  *
Emergency Contact Phone Number:  * List anyone who CAN NOT pick up your child?   
Emergency Alternate Number:
 
Other Information
We wish to post photos of activities on our website for you and other family members to enjoy.  Your privacy however is important to us!    
Are you willing to sign a photo release form allowing us to post photos of your child in action?
 Yes      No      Maybe*
We will not place your child's name anywhere on our website!
-->  View the Image Release Form  <--
Has your child attended our VBS programs in the past?
 Yes    No   *

Confirmation
Fields marked with an * are required.