Vacation Bible School
Week of July 22 2013 – 9:00AM- 11:15 AM
Participant Registration
(3 years old on or before 7/1/13 through Age 6)
*3 Year olds MUST be potty trained and have classroom setting experience
We look forward to you joining us for this fresh combination of faith and fun!
*Required fields
*First Name: ______________________________________
*Last Name: ______________________________________
*Street Address: _______________________________________________________________________________
*City / State / Zip Code _________________________________________________________________________
*Home Phone: _____________________________ Other Phone: ______________________________________
Email Address: _________________________________________________________________________________
Emergency and Guardian Information
*Allergies & Medical Information: ________________________________________________________________
_____________________________________________________________________________________________
Emergency Contact Name: _______________________________________________________________________
Emergency Contact Phone: _____________________ Emergency Contact Relationship: ____________________
Primary Pickup Name: __________________________________________________________________________
Primary Pickup Phone Number: ________________________________________
*Music CD $3.00 YES _____ NO _____ (free for all registrations received by 5/1/13 – one per family)
*T-Shirt: $6 YES_____ NO _____
if YES (circle one) – SIZE XS (2-4) S (6-8) M (10-12) L (14-16)
3 Year Olds - Potty Trained: Yes _____ No _____
Previous classroom experience: Yes____ No ____
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*I have completed the Volunteer Registration form: Yes ____
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Age as of 7/1/13: ____________
