VBS Child Registration

All fields with a * are required fields.

Child 1

*Child Name :

*Gender :

*Birthdate :

*Grade Completed :

*Address :

*City :

*State :

*Zip :

*Parents/Guardian :

*Home Phone :

*Work Phone :

*Cell Phone :

*Email Address :

*Emergency contact :

*Relationship to child :

*Phone :

*Please place my child with :

*Name of home church :

*Food Allergies :

*Medical Concerns :

Child 2

Child Name :

Gender :

Birthdate :

Grade Completed :

Address :

City :

State :

Zip :

Parents/Guardian :

Home Phone :

Work Phone :

Cell Phone :

Email Address :

Emergency contact :

Relationship to child :

Phone :

Please place my child with :

Name of home church :

Food Allergies :

Medical Concerns :

Child 3

Child Name :

Gender :

Birthdate :

Grade Completed :

Address :

City :

State :

Zip :

Parents/Guardian :

Home Phone :

Work Phone :

Cell Phone :

Email Address :

Emergency contact :

Relationship to child :

Phone :

Please place my child with :

Name of home church :

Food Allergies :

Medical Concerns :

18059 Leesville Road - Evington, VA - Phone: 434.525.5880 - www.leesvilleroad.net Where Ministry is About Doing Life Together.