Child's name *

First

Last

Child's age *

Name of parents/guardians *

First

Last

Street address *

City, State and Zip *

Parent/guardian's phone numbers *

Allergies or medical conditions (i.e. diabetes)

In case of emergency, please contact *

Emergency phone numbers *

I give permission to call 911 in case of emergency. *

Photographs will be taken during VBS. My signature indicates I am giving permission for my child’s photo to be taken. *

Please indicate if your child has any special needs we should be aware of.

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