VBS 2011 Children's Registration
Parent Name
*
Parent Name 2
Email
*
Address 1
*
Address 2
City
*
State
*
Zip Code
*
Home Phone
*
Cell Phone
Child's Name
*
Sex
*
Male
Female
What does your child like to be called?
*
Date of Birth - mm/dd/yy
*
Grade Completed
*
PBC Member
*
Yes
No
If No What church do you attend?
Emergency Contact (other than parent)
*
Phone
*
Relationship to child
*
Any Allergies? (esp. food)
Illness/Activity Restrictions?
Child's Physician
Phone
One (1) friend to place your child with? (If possible)
Questions & Comments?