September 3rd, 2010
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VBS Registration
* Required
Child's First Name: *
Child's Last Name: *
Date of Birth:
Grade Completed:
Age: *
Parent's First Name:
Parent's Last Name:
Address: *
City: *
State: *
Zip: *
Home Phone:
Cell Phone:
E-mail:
Emergency First Name:
Emergency Last Name:
Emergency Phone: *
Is there a special friend your child would like to be with?
Special Needs / Allergies:
Transportation needed:
Person Responsible for Pickup after VBS:
Their phone number:
Relationship to child: