VBS Registration Form

Family Information Parent First Name  Parent Last Name

Address City Zip Code

Home Phone # Work Phone # Cell Phone #

E-mail Address

Emergency Health Care Name Emergency Health Care Phone #


1st Child's Information Child's Name   Date of Birth

PreK Level OR Grade Completed

Allergies or medical concerns


2nd Child's Information Child's Name   Date of Birth

PreK Level OR Grade Completed

Allergies or medical concerns


3rd Child's Information Child's Name   Date of Birth

PreK Level OR Grade Completed

Allergies or medical concerns


4th Child's Information Child's Name   Date of Birth

PreK Level OR Grade Completed

Allergies or medical concerns


Can you bring snacks/juice?  yes no

  I give permission for my child to take part in all the activities of the 2012 Vacation Bible School and photos to be published for West Middleton Lutheran Church. Checking the box is parental consent.