VBS Registration - July 17-21

Child's Name*

First Last

Gender*

Age (3 and potty trained- entering 6th grade)*

Grade Completed*

Medical Issues/ Allergies

Parent Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Parent Email*

Parent Cell Phone*

Parent Home Phone

Home Church*

Enter information for a second child if applicable

Child's Name

First Last

Gender

Age (3 and potty trained-entering 6th grade)

Grade Completed

Medical Issues/ Allergies

Child's Name

First Last

Gender

Grade Completed

Age (3 and potty trained-entering 6th grade)

Medical Issues/ Allergies

May Peace Lutheran use photos or videos with the image of your child(ren) in a legal way for promotion and advertisement?*