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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.
