Elim Church - VBS CC Registration

VBS CC Registration - 2019

Child's Name (First and Last)	*
Child's Age	*
Date of Birth (mm/dd/year)	*
Last school grade completed	*
Name of parent(s)	*
Street Address	*
City	*
State	*
ZIP	*
Home Telephone
Parent/caregiver's cell phone:
In case of emergency, contact	*
Relationship to child	*
Emergency Contacts Phone number	*
Home Church
Do you give permission to have your child's photo taken and used for Adventure Chapel advertisements, FB, flyers, etc.	*
Allergies or other medical conditions
By submitting this form you are electronically giving your signature and permission to register your child to this years VBS program. Thank you and we look forward to having a blast learning about Jesus with your child!
Electronic Signature: First and Last Name	*
Your Email Address	*
Please type in the box to the right »	*